Abstract
Lustbader D, Pekmezaris R, Frankenthaler M, et al. Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients. Pall Support Care 2011; 9:401-406.
Critically ill patients admitted to medical intensive care units (MICU) often have prolonged lengths of stay and poor outcome. Decisions to forgo or withdraw life-sustaining treatments are the most difficult conversations for clinicians and surrogates when interventions such as dialysis, mechanical ventilation, and the use of vasopressors are discussed. In this retrospective study of two cohorts, the authors attempted to assess the impact of palliative medicine consultation on MICU and hospital length of stay, do-not-resuscitate (DNR) designation, and location of death for MICU patients who died while hospitalized. Patients admitted to a tertiary care university-affiliated hospital MICU from January 1, 2003 to June 30, 2004 (n=515) were compared to MICU patients who had a palliative medicine consultation from January 1, 2005 to June 1, 2009 (n=693). Only patients who died during hospitalization in both cohorts were considered for the study. Results demonstrated that palliative medicine consultation reduced time until death during the entire hospitalization. Time from MICU admission until death was also reduced, further demonstrating the impact of palliative medicine consultation on the duration of dying of hospitalized patients. The intervention group (palliative medicine consultation) contained a significantly higher percentage of patients with DNR designation at death than did the control group. The authors conclude that palliative medicine consultation is associated with an increased rate of DNR designation and reduced time until death. Patients in the intervention group were also more likely to die outside the MICU when compared to the control group.
Kiske WD, Jobes J, Xiang Q, et al. The effects of ethanol on the bioavailability of oxymorphone extended-release tablets and oxymorphone crush-resistant extended- release tablets. J Pain 2012;13:90-99.
Adverse events may occur with extended-release (ER) opioid products if tampering or coadministration with ethanol causes excessive exposure (dose dumping) to the opioid. The effects of ethanol on the in vitro dissolution and in vivo pharmacokinetics of oxymorphone ER and oxymorphone crush-resistant formulation (CRF) were evaluated. In vitro dissolution rates were measured for oxymorphone ER 40 mg and oxymorphone CRF 40 mg tablets in aqueous solutions of 0% to 40% ethanol. In two in vivo, open-label, randomized, crossover studies, fasted healthy volunteers received single oral doses of oxymorphone ER 40 mg or oxymorphone CRF 40 mg with 240 mL of 0% to 40% ethanol. Naltrexone was used to minimize opioid effects. In the in vitro analyses, dissolution rates of oxymorphone ER and CRF were unaffected in aqueous solutions of≤40% ethanol. Coadministration of oxymorphone ER or oxymorphone CRF with ethanol 20% and 40% increased oxymorphone peak plasma concentrations (C(max)) by 14% to 80% and reduced time to C(max). For both formulations, oxymorphone area under the curve and terminal half-life were largely unaffected, but C (max) increased with ethanol dose. Neither oxymorphone formulation exhibited dose dumping in terms of overall exposure when ingested with ethanol. The authors conclude that administering oxymorphone ER or oxymorphone CRF with 240 mL of ≤40% ethanol increased oxymorphone C (max) without dose dumping in terms of area under the curve. These results provide reassurance about the integrity of oxymorphone ER formulations with ethanol. Nonetheless, the authors recommend that alcohol and opioids never be combined because of the risk of respiratory depression.
Nieder C, Tollali T, Pawinski A, Bremnes RM. A population-based study of the pattern of terminal care and hospital death in patients with non-small cell lung cancer. Anticancer Res 2012;32:189-194.
Non-small cell lung cancer (NSCLC) is a major cause of cancer-related death as well as use of health care resources worldwide. Significant costs are generated in the months before death, with hospitalization the major cost driver. Moreover, hospital death may cause physical and emotional distress. The authors of this study analyzed factors predicting the likelihood of hospital death in patients with NSCLC. Patients who died from NSCLC (any stage and treatment) during a recent five-year interval up to December 31, 2010, within a defined geographical region of northern Norway, were included in the study (n=112). Only 15% of all patients did not require any hospitalization during their last three months. Twenty-four percent of patients died at home, 53% in hospital, and 23% in nursing homes. The likelihood of hospital death was independent of initial management and time between diagnosis and death. For example, 45% of patients treated with the best supportive care died in the hospital. Multivariate analysis revealed that initial tumor stage of T4, systemic therapy during the last three months of life, and any active therapy during the last four weeks significantly increased the likelihood of hospital death, while early discussion of resuscitation preferences reduced it. The authors conclude that these four parameters suggest that early focus on symptom palliation and resuscitation preferences are crucial components of strategies improving terminal care. Patients with T4 tumors might experience unsatisfactory symptom control and should be offered a part in prospective studies addressing these issues.
Stark LL, Tofthagen C, Visovsky C, McMillan SC. The symptom experience of patients with cancer. J Hosp Palliat Nurs 2012;14:61-70.
In spite of recent advances in supportive cancer care, unrelieved symptoms continue to be prevalent and persistent in the cancer patient population. In an attempt to describe the symptom experience of patients with cancer and pain, including the mean number of symptoms reported, the most commonly occurring symptoms, symptoms with the highest severity, and the symptoms causing the most distress, the authors analyzed data gathered for a larger ongoing National Institutes of Health–funded study of medication-induced constipation. The sample consisted of 393 outpatients at a National Cancer Institute–designated cancer center in west-central Florida, 70% with advanced disease. The sample was predominantly female (57.7%); either breast or lung cancer or lymphoma (53.7%); and stage III or IV disease (51.3%). Two hundred ninety-eight of the 393 (75.8%) patients for whom data were available reported pain and were included in the analysis. Patients reported between 2 and 30 symptoms, each with a mean of 14.1 (SD, 5.5). As in earlier symptom studies of cancer patients, fatigue was the most commonly reported, occurring in more than 91% of patients. The next most frequently reported symptoms were feeling drowsy (66.8%, n=199), difficulty sleeping (65.8%, n=196), and worrying (n=193, 64.8%). Symptoms with the greatest severity were hair loss and impaired sexual activity, which were reported to be severe or very severe by more than 50% of the patients who had these symptoms. However, lack of energy/fatigue, pain, and difficulty sleeping were the most distressing problems and were reported to be quite a bit or very bothersome by at least 50% of patients with each symptom. Pain, fatigue, and difficulty sleeping continue to be among the most frequently reported and distressing symptoms for persons with cancer. The authors conclude that in addition to asking about the presence of symptoms patients may be experiencing, nurses must also inquire about the associated distress, and that knowing which symptoms are causing the most distress for patients will assist in prioritizing patient care and providing the much needed support and education for this population. The authors also suggest that continued attention on treating these symptoms should be the focus of ongoing research as well as nursing education both in service areas and in schools of nursing.
Prommer E. Role of codeine in palliative care. J Opioid Manage 2011;7:401-406.
Codeine is designated as one of the essential medicines of palliative care for symptoms such as pain and diarrhea. Essential drugs for palliative care are defined as drugs that are effective for the treatment of common symptoms in palliative medicine, are easily available, and are affordable. Codeine is recommended for the management of mild to moderate pain and is available as a combination product or as a standalone opioid. It is a pro-drug and exhibits an affinity to micro-opioid receptors 200 times lower than morphine. Codeine is metabolized in the liver to inactive metabolites, which account for 90% of the transformed product, and morphine, which accounts for 10% of the transformed product and provides the main analgesic effect. The production of morphine is dependent on cytochrome oxidase 2D6 enzyme activity, which may not be fully active in select populations. The author states that the purpose of this review is to examine the efficacy of codeine for common symptoms encountered in palliative medicine, which has led to its designation as an essential medicine for palliative care.
Greer JA, Pirl WF, Jackson VA, Muzikansky A, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with non-small-cell lung cancer. J Clin Oncol 2011; December 27 (published online ahead of print publication).
Recent research (Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-742) demonstrates that introducing palliative care soon after diagnosis for patients with metastatic non-small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. In this secondary analysis based on a randomized controlled trial of 151 patients with newly diagnosed NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009, the authors attempted to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients. Participants in this study received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included number and types of chemotherapy regimens, and frequency and timing of chemotherapy administration and hospice referral. Results demonstrated that the overall number of chemotherapy regimens did not differ significantly by study group. However, compared with those in the standard care group, participants receiving early palliative care had half the odds of receiving chemotherapy within 60 days of death (odds ratio 0.47, 95% confidence interval (CI) 0.23 - 0.99; p=.05); a longer interval between the last dose of intravenous chemotherapy and death (median 64.0 days [range 3 - 406 days] versus 40.5 days [range 6 - 287 days]; p=.02); and higher enrollment in hospice care for longer than one week (60.0% [36 of 60 patients] versus 33.3% [21 of 63 patients]; p=.004). The authors conclude that while patients with metastatic NSCLC received similar numbers of chemotherapy regimens in the sample, early palliative care optimized the timing of final chemotherapy administration and transition to hospice services, key measures of high-quality end-of-life care.