Abstract
Bakitas M, Macmartin M, Trzepowski K, et al. Palliative care consultations for heart failure patients: How many, when, and why? J Card Fail 2013;19:193–201.
Heart failure (HF) is an increasing population for palliative care consultation. In this article the authors attempted to characterize the HF population receiving palliative care consultations (PCCs). In a chart review from January 2006 to April 2011 the authors analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, a content analysis of PCC notes was conducted to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted one-year mortality of 29% and median life expectancy of 2.8 years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%). The authors conclude that despite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.
Abraham A, Drory VE. Postradiation lower motor neuron syndrome: Case series and literature review. J Neurol 2013. E-pub ahead of print. DOI: 10.1007/s00415-013-6881-7.
A variety of neurological syndromes has been described after irradiation of the distal spinal cord and cauda equina, mainly as treatment for testicular cancer and lymphoma. One of these syndromes is a rare lower motor neuron syndrome, manifested by flaccid paraparesis. Medical files of patients with postradiation lower motor neuron syndrome treated in the author's neuromuscular clinic from 2005 to 2012 were reviewed. The diagnosis was based on past irradiation of the distal spinal cord and cauda equina, slowly progressive lower limb weakness, characteristic electrophysiological studies, and no alternative diagnosis. In addition, a systematic review of the literature on similar cases was performed using PubMed. The authors identified five patients with postradiation lower motor neuron syndrome in clinic charts. Three of them were irradiated due to seminoma, and the other two due to lymphoma. Forty-five additional similar cases were found in a literature search, mainly male (89%), with testicular cancer (67%), irradiated at mean age of 33 years, with an average irradiation dose of 5,225 cGy (range 3000–14,600), and a latency period between irradiation and symptoms onset ranging from 3 months to 27 years (average 9 years). Magnetic resonance imaging was done only in a few, showing gadolinium enhancement of the cauda equina in close to half of them (7/16). The authors conclude that their patients and those previously described in the literature form a distinct clinical and electrophysiological syndrome that might be more frequent than previously expected, and should be not overlooked.
Kim SY, Kim JM, Kim SW, et al. Does awareness of terminal status influence survival and quality of life in terminally ill cancer patients? Psychooncology 2013. E-pub ahead of print. DOI: 10.1002/pon.3275.
Clinical studies on the impact of disclosing a prognosis on a patient's psychological or physical conditions are rare. In this prospective cohort study of terminally ill patients the authors investigated the effect of patient awareness of terminal status on survival and quality of life (QoL) in a palliative care setting. Patients with terminal cancer at a palliative care unit were enrolled consecutively. The patients' awareness of terminal status was determined using a semistructured interview. Sociodemographic and clinical characteristics, including Eastern Cooperative Oncology Group performance status, depressed mood, and QoL, were investigated. To determine the independent effects of awareness of illness on survival and QoL, multivariate Cox proportional-hazards regression and multivariate linear regression were used, respectively. Results demonstrated that for the 262 cases analyzed, the median survival time was 28.5 (15.8–55.3) days, and 76 (29.0%) patients were unaware of their prognosis. Patients who were aware survived for a shorter period than did those who were unaware after adjusting for clinical variables including physical status and depression. Also, patients who were aware reported lower subjective QoL compared with patients who were unaware in a multivariate linear regression analysis. The authors conclude that awareness of prognosis may negatively impact survival and QoL in terminally ill cancer patients. Therefore, the patient's preference for and individual susceptibility to receiving such information should be assessed carefully before disclosure.
Dobs AS, Boccia RV, Croot CC, et al. Effects of enobosarm on muscle wasting and physical function in patients with cancer: A double-blind, randomised controlled phase 2 trial. Lancet Oncol 2013. E-pub ahead of print. DOI: 10.1016/S1470-2045(13)70055.
Cancer-induced muscle wasting begins early in the course of a patient's malignant disease, resulting in declining physical function and other detrimental clinical consequences, including reduced quality of life. This randomized, double-blind, placebo-controlled phase 2 trial assessed the efficacy and safety of enobosarm, a selective androgen receptor modulator, in patients with cancer. The authors enrolled male (>45 years) and female (postmenopausal) patients with cancer who were not obese and who had at least 2% weight loss in the previous six months. Participants were randomly assigned (1:1:1 ratio, by computer generated list, block size three, stratified by cancer type) to receive once-daily oral enobosarm 1 mg, 3 mg, or placebo for up to 113 days at U.S. and Argentinian oncology clinics. The sponsor, study personnel, and participants were masked to assignment. The primary endpoint was change in total lean body mass from baseline, assessed by dual-energy x-ray absorptiometry. Efficacy analyses were done only in patients who had a baseline and an on-treatment assessment in the protocol-specified window of within 10 days before baseline or first study drug, and within 10 days of day 113 or end of study (evaluable efficacy population). Results demonstrated that 159 patients were analyzed for safety (placebo, n=52; enobosarm 1 mg, n=53; enobosarm 3 mg, n=54). The evaluable efficacy population included 100 participants (placebo, n=34; enobosarm 1 mg, n=32; enobosarm 3 mg, n=34). Compared with baseline, significant increases in total lean body mass by day 113 or end of study were noted in both enobosarm groups. Change in total lean body mass within the placebo group was not significant (p=0.88). The most common serious adverse events were malignant neoplasm progression (8 of 52 [15%] with placebo versus 5 of 53 [9%] with enobosarm 1 mg versus 7 of 54 [13%] with enobosarm 3 mg); pneumonia (2 [4%] versus 2 [4%] versus 3 [6%]); and febrile neutropenia (3 [6%] versus 1 [2%] versus 0). However, none of these events were deemed related to the study drug. The authors conclude that cancer cachexia is an unmet medical need and that their data suggest that use of enobosarm might lead to improvements in lean body mass, without the toxic effects associated with androgens and progestational agents.
Gal TB, Jaarsma T. Self-care and communication issues at the end of life of recipients of a left-ventricular assist device as destination therapy. Curr Opin Support Palliat Care 2013;7:29–35.
The purpose of this review was to provide an overview of self-care and communication issues at the end of life of patients with left-ventricular assist devices (LVADs) for destination therapy, based on recent research on end-of-life communication in other diseases. For many patients with advanced heart failure, LVADs as destination therapy improve survival and quality of life. However, LVADs can be associated with complications, new comorbidities, or worsening of previous conditions, resulting in decreased quality of life and limited prognosis, raising the need for planning palliative and end-of-life care. Open communication addressing the consequences of the LVAD implantation for daily life and the future (including advance directives) is advised in different stages of the treatment, involving a multidisciplinary team taking care of these complex patients and their caregivers. The authors conclude that health care professionals treating patients before and after LVAD implantation need to take an active role in end-of-life discussions and be able to communicate information regarding expected complications, quality of life, and prognosis to the patients and caregivers. Moreover, research is needed addressing optimal ways and timing of communication with LVAD patients and families.
Kelley AS, McGarry K, Fahle S, Marshall SM. Out-of-pocket spending in the last five years of life. J Gen Intern Med 2013;28:304–309.
A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket health care expenditures, yet little is known about cumulative financial risks arising from out-of-pocket health care expenditures faced by older adults, particularly near the end of life. Using the nationally representative Health and Retirement Study (HRS) cohort, the authors conducted retrospective analyses of Medicare beneficiaries' total out-of-pocket health care expenditures over the last five years of life. HRS decedents between 2002 and 2008 were identified; the authors defined a five-year study period using each subject's date of death, and excluded those without Medicare coverage at the beginning of this period (n=3209). Total out-of-pocket health care expenditures in the last five years of life and expenditures as a percentage of baseline household assets were examined. The authors then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 U.S. dollars. Results demonstrated that average out-of-pocket expenditures in the five years prior to death were $38,688 for individuals and $51,030 for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25% of subjects' expenditures exceeded baseline total household assets, and 43% of subjects' spending surpassed their nonhousing assets. Among those survived by a spouse, 10% exceeded total baseline assets and 24% exceeded nonhousing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease to $66,155 for Alzheimer's disease. The authors conclude that despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket health care expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last five years of life.