Abstract
Koesel N, Link M: Conflicts in goals of care at the end of life: Are aggressive life-prolonging interventions and a ‘‘Good Death’’ compatible? J Hosp Palliat Nurse 2014;16:330–335.
Recent medical literature reports increased utilization of the intensive care unit (ICU) at the end of life, even for patients who are considered terminally ill, and the overall ICU adult mortality rate ranges from 10% to 29%. Therefore, ICU nurses require a level of comfort in caring for patients and families at this vulnerable time. At times, ongoing aggressive life-prolonging interventions for a terminally ill patient can create ethical conflicts and moral distress for nurses. This leads to the question: Can this level of treatment be compatible with a ‘‘good death?’’ Medical recommendations are made based on the patient's goals of care, appropriate treatment options, and associated benefits and burdens. How then should nurses respond when a patient or family does not agree with these medical recommendations? Through a case study, this article explores the moral and ethical conflicts that often occur in the ICU setting at end of life and aid to empower the ICU nurse to care for patients in a way that honors the patient's wishes and maintains a healthy nurse-patient relationship.
Jones BL, Contro N, Koch KD: The duty of the physician to care for the family in pediatric palliative care: Context, communication, and caring. Pediatr 2014;133:S8–S15.
Pediatric palliative care physicians have an ethical duty to care for the families of children with life-threatening conditions throughout their illness and bereavement. This duty is predicated on two important factors: (1) best interest of the child and (2) nonabandonment. Children exist in the context of a family and therefore excellent care for the child must include attention to the needs of the family, including siblings. The principle of nonabandonment is an important one in pediatric palliative care, as many families report being well cared for during their child's treatment, but feel as if the physicians and team members suddenly disappear after the death of the child. Family-centered care requires frequent, kind, and accurate communication with parents that leads to shared decision making during treatment, care of parents and siblings at the end of life, and assistance to the family in bereavement after death. Despite the challenges to this comprehensive care, physicians can support and be supported by their transdisciplinary palliative care team members in providing compassionate, ethical, and holistic care to the entire family when a child is ill.
Cooper RS, Ferguson A, Bodurtha JN, Sith TJ: AMEN in challenging conversations: Bridging the gaps between faith, hope, and medicine. J Oncol Pract 2014;10:e19–e195.
All health care practitioners face patients and families in desperate situations who say, “We are hoping for a miracle.” Few providers have any formal training in responding to this common, difficult, and challenging situation. We want to do our best to preserve hope, dignity, and faith while presenting the medical issues in a nonconfrontational and helpful way. The authors present the acronym AMEN (affirm, meet, educate, no matter what) as one useful tool to negotiate these ongoing conversations.
Paulsen O, Klepstad P, Rosland JH, et al.: Efficacy of methylprednisolone on pain, fatigue, and appetite loss in patients with advanced cancer using opioids: A randomized, placebo-controlled, double-blind trial. J Clin Oncol 2014. (E-pub ahead of print.)
Corticosteroids are frequently used in cancer pain management despite limited clinical evidence. This study compares the analgesic efficacy of corticosteroid therapy with placebo. Adult patients with cancer receiving opioids with average pain intensity ≥4 (numeric rating scale [NRS] 0 to 10) in the last 24 hours were eligible. Patients were randomly assigned to methylprednisolone (MP) 16 mg twice daily or placebo (PL) for seven days. Primary outcome was average pain intensity measured at day 7 (NRS, 0 to 10); secondary outcomes were analgesic consumption (oral morphine equivalents), fatigue and appetite loss (European Organization for Research and Treatment of Cancer–Quality of Life Questionnaire C30, 0 to 100); and patient satisfaction (NRS, 0 to 10). Results demonstrated that a total of 592 patients were screened; 50 were randomly assigned and 47 were analyzed. Baseline opioid level was 269.9 mg in the MP arm and 160.4 mg in the PL arm. At day 7 evaluation there was no difference between the groups in pain intensity (P=0.880) or relative analgesic consumption (P=0.950). Clinically and statistically significant improvements were found in fatigue (P= 0.003), appetite loss (P=0.003), and patient satisfaction (P=0.001) in favor of the MP compared with the PL group, respectively. There were no differences in adverse effects between the groups. The authors conclude that MP 32 mg daily did not provide additional analgesia in patients with cancer receiving opioids, but it improved fatigue, appetite loss, and patient satisfaction. Clinical benefit beyond a short-term effect must be examined in a future study.
Minniti G, Enrici RM: Radiation therapy for older adults with glioblastoma: Radical treatment, palliative treatment, or no treatment at all? J Neurooncol 2014. (E-pub ahead of print.)
The incidence of glioblastoma in older adults has increased over the last few decades. Current treatment includes surgery, radiotherapy, and chemotherapy, but optimal disease management remains a matter of debate. Both standard (60 Gy in 30 daily fractions) and hypofractionated radiotherapy (30–40 Gy in 10–15 daily fractions) have been employed with a similar survival benefit. Recent randomized studies indicate that chemotherapy with the alkylating agent temozolomide is a safe and effective therapeutic option for patients aged 60 years or older with newly diagnosed glioblastoma, suggesting that it should be a sufficient treatment for patients presenting with a methylated O6-methylguanine-DNA methyltransferase (MGMT) promoter gene. The addition of concomitant temozolomide chemotherapy, adjuvant temozolomide chemotherapy, or both to postoperative radiotherapy, which is the standard treatment for adults with glioblastoma, has been associated with a survival benefit for older patients with a good performance status; however, aggressive treatment in this population may be associated with a high risk of neurological toxicity and deterioration of quality of life. Survival stratification according to age, MGMT promoter methylation status, and neurological status may be useful for clinical decision making and designing randomized trials for adequately evaluating the optimal combination of radiotherapy and chemotherapy for older patients with glioblastoma.
Boersma I, Miyasaki J, Kutner J, Kluger B: Palliative care and neurology: Time for a paradigm shift. Neurol 2014;83:561–567.
Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article the authors aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? The authors cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. The authors conclude by suggesting areas for future educational efforts and research.