Abstract
Smith SK, Zimmerman S, Williams CS, et al. Post-traumatic stress symptoms in long-term non-Hodgkin's lymphoma survivors: Does time heal? J Clin Oncol 2011;29:4526–4533.
As the rate of survival of non-Hodgkin's lymphoma (NHL) has increased, it has become apparent that little is known about the trajectory of posttraumatic stress disorder (PTSD) symptoms in cancer survivors, despite the fact that such knowledge can guide treatment. Therefore, the authors of this study examined changes in PTSD symptoms among long-term survivors of NHL and identified demographic, clinical, and psychosocial predictors and correlates of PTSD symptomatology. Surveys were mailed to 682 NHL survivors who participated in an earlier survey and who were at least 7 years postdiagnosis. Information was obtained regarding PTSD symptoms, positive and negative perceptions of the cancer experience (i.e., impact of cancer), and other potential correlates of PTSD. A total of 566 individuals participated (83% response rate) with a median of 12.9 years since diagnosis; respondents were 52% female and 87% white. Although half (51%) of the respondents reported no PTSD symptoms and 12% reported a resolution of symptoms, more than one third (37%) reported persistence or worsening of symptoms over 5 years. Survivors who reported a low income, stage of disease ≥2 at diagnosis, aggressive lymphoma, having received chemotherapy, and greater impact of cancer (both positive and negative) at the initial survey had more PTSD symptoms at follow-up. In multivariable analysis, income and negative impacts of cancer were independent predictors of PTSD symptoms. The authors concluded that more than one third of long-term NHL survivors experience persisting or worsening PTSD symptoms, and that providers should be aware of enduring risk. Early identification of those at prolonged risk with standardized measures and treatments that target perceptions of the cancer experience might improve long-term outcomes.
Petrucci RJ, Benish LA, Carrow BL, et al. Ethical considerations for ventricular assist device support: A 10-point model. ASAIO Journal 2011;57:268–273.
The potential for long-term support on a ventricular assist device (VAD) in the bridge-to-transplant (BTT) and destination therapy (DT) settings has created unprecedented ethical challenges for patients and caregivers. Concerns include the patient's adaptation to life on a device and the ethical, clinical, and practical issues associated with living on mechanical support. On the basis of the authors' experience treating 175 consecutive VAD patients, they developed a model to address the ethical and psychosocial needs of patients undergoing VAD implantation. Patient preparation for VAD implantation encompasses three phases: 1) initial information regarding the physical events involved in implantation, risks and benefits of current device technology, and the use of VAD as a rescue device; 2) pre-implant preparation including completion of advance directives specific to BTT/DT, competency determination, and identifying a patient spokesperson, multidisciplinary consultants, and cultural preferences regarding device withdrawal; and 3) VAD-specific end-of-life issues including plans for device replacement and palliative care with hospice or device withdrawal. This 3-phase 10-point model addresses the ethical and psychosocial issues that should be discussed with patients undergoing VAD support. This article is highly recommended for all hospice and palliative care clinicians.
Robinson CA, Pesut B, Bottorff JL, et al. Issues in rural palliative care: Views from the countryside. J Rural Health 2010;26:78–84.
Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice and palliative services are an essential need in both urban and rural settings. However, rural communities in particular are vulnerable to receiving inadequate services due to their geographic isolation. In this study the authors attempted to better understand experiences and issues related to rural palliative care. Focus groups were held for health professionals, family members, and volunteers in three rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique. Results demonstrated three themes in rural palliative care: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural, and health aspects of residents in order to optimize care. The authors concluded that tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.
Khot S, Billings M, Owens D, Longstreth D. Coping with death and dying on a neurology inpatient service. Death rounds as an educational initiative for residents. Arch Neurol 2011;68:1395–1397.
Residents in neurology may feel unprepared to care for dying patients. The authors developed death rounds (DR) to provide emotional support and end-of-life (EOL) care teaching for residents caring for dying patients on the inpatient neurology service. DRs are monthly one-hour clinical case discussions where residents identify issues through shared experiences. The objective of this study was to survey neurology residents' perceptions of DR with respect to EOL care teaching and emotional support. The authors conducted an electronic survey of all (n=26) neurology residents and recent residency graduates at the University of Washington two years after instituting monthly DR. The survey consisted of 10 questions examining residents' perceptions of the extent to which DR provided emotional support and EOL care teaching. The authors dichotomized responses to statements about DR as “agree” or “disagree.” All 26 residents responded to the survey and attended at least one DR session. More than half of residents attended more than three sessions. Residents agreed that DR helped them cope with dying patients (17 residents [65%]), delivered closure for the team (16 residents [61%]), and provided emotional support, more for the team (18 residents [69%]) than the individual (10 residents [38%]). Most residents felt that DR provided useful teaching about EOL care (18 residents [69%]), and they were satisfied overall with DR (16 residents [61%]). The authors concluded that DRs afford an opportunity for physicians-in-training as a group to process their feelings, intense emotions, and insecurities while learning from the dying process.
Seccareccia D, Gebarra N. Pruritus in palliative care. Getting up to scratch. Can Fam Phys 2011;57:1010–1013.
Pruritus is a difficult symptom to treat that can significantly reduce the quality of life of patients. In this case-based article, the author discusses the various etiologies and treatments for itching. This is a quick read with valuable information.
Postmus D, Pari AAA, Jaarsma T, et al. A trial-based economic evaluation of 2 nurse-led disease management programs in heart failure. Am Heart J 2011;162:1096–1104.
Although previously conducted meta-analyses suggest that nurse-led disease management programs in heart failure (HF) can improve patient outcomes, uncertainty regarding the cost-effectiveness of such programs remains. In this study the authors attempted to compare the relative merits of two variants of a nurse-led disease management program (basic or intensive support by a nurse specialized in the management of patients with HF) against care as usual (routine follow-up by a cardiologist), and a trial-based economic evaluation was conducted alongside the Coordinated study evaluating Outcomes of Advising and Counseling in Heart failure (COACH) study. Results demonstrated that in terms of costs per life-year, basic support was found to dominate care as usual, whereas the incremental cost-effectiveness ratio between intensive support and basic support was found to be equal to 532,762 euros per life-year; in terms of costs per quality-adjusted life-year (QALY), basic support was found to dominate both care as usual and intensive support. An assessment of the uncertainty surrounding these findings showed that, at a threshold value of 20,000 euros per life-year/20,000 euros per QALY, basic support was found to have a probability of 69%/62% of being optimal against 17%/30% and 14%/8% for care as usual and intensive support, respectively. The results of the subgroup analysis suggest that a stratified approach based on offering basic support to patients with mild to moderate HF and intensive support to patients with severe HF would be optimal if the willingness-to-pay threshold exceeds 45,345 euros per life-year/59,289 euros per QALY. The authors concluded that although the differences in costs and effects among the three study groups were not statistically significant, from a decision-making perspective, basic support had a relatively large probability of generating the highest health outcomes at the lowest costs. The results also substantiated that a stratified approach based on offering basic support to patients with mild to moderate HF and intensive support to patients with severe HF could further improve health outcomes at slightly higher costs.