Abstract
Kuczewski MG, McCarthy MP, Michelfeldder A, et al. “I will never let that be ok again:” Student reflections on competent spiritual care for dying patients. Acad Med 2014;89:54–59.
The purpose of this study was to examine medical students' reflections on the spiritual care of a patient who has died so as to understand how students experienced this significant event and how they or their teams addressed patients' spiritual needs. In 2010 to 2011, the authors gave third-year students at Loyola University Chicago Stritch School of Medicine an essay assignment, prompting them to reflect on the experience of the death of one of their patients. The authors analyzed the content of the essays using an iterative, multistep process. Three authors independently coded the essays for themes based on the competencies (developed by Puchalski and colleagues and reflected in the essay prompt) of communication, compassionate presence, patient care, and personal and professional development. The authors reached consensus through discussion. Results demonstrated that a salient theme in the students' writings was awareness of their personal and professional development. Students reported being aware that they were becoming desensitized to the human dimension of care, and particularly to dying patients and their families. Students wished to learn to contain their emotions to better serve their patients, and they articulated a commitment to addressing patient and family needs. Students identified systemic fragmentation of patient care as a barrier to meeting patient needs and as a facilitator of provider desensitization. The authors conclude that written student reflections are a rich source of data regarding the spiritual care of dying patients and their families. They provide insight into the personal and professional development of medical students and suggest that medical schools should support students' formation.
Kenis C, Decoster L, Van Puyvelde K, et al. Performance of two geriatric screening tools in older patients with cancer. J Clin Oncol 2014;32:19–26.
The purpose of this study was to compare the diagnostic characteristics of two geriatric screening tools—G8 and the Flemish version of the Triage Risk Screening Tool (fTRST)—to identify patients with a geriatric risk profile and to evaluate their prognostic value for functional decline and overall survival (OS). Patients 70 years old with a malignant tumor were included if a new cancer event occurred requiring a treatment decision. Geriatric screening with G8 and fTRST—cutoff 1 [fTRST (1)] and cutoff 2 [fTRST (2)] evaluated—was performed in all patients, as well as a geriatric assessment (GA) evaluating social situation, functionality in terms of activities of daily living (ADL), instrumental activities of daily living (IADL), cognition, depression, and nutrition. Functionality was reevaluated two to three months after cancer treatment decision, and death rate was followed. Functional decline and OS were evaluated in relation to normal versus abnormal score on both screening tools. Results demonstrated that 937 patients were included (October 2009 to July 2011). G8 and fTRST (1) showed high sensitivity (86.5% to 91.3%) and moderate negative predictive value (61.3% to 63.4%) to detect patients with a geriatric risk profile. G8 and fTRST (1) were strongly prognostic for functional decline on ADL and IADL, and G8, fTRST (1), and fTRST (2) were prognostic for OS. G8 had the strongest prognostic value for OS. The authors conclude that both geriatric screening tools, G8 and fTRST, are simple and useful instruments in older patients with cancer for identifying patients with a geriatric risk profile and have a strong prognostic value for functional decline and OS.
Molina KM, Shrader P, Colan SD, et al. Predictors of disease progression in pediatric dilated cardiomyopathy. Circ Heart Fail 2013;6:1214–1222.
Despite medical advances, children with dilated cardiomyopathy (DCM) remain at high risk of death or need for cardiac transplantation. In this study, the authors sought to identify predictors of disease progression in pediatric DCM. The Pediatric Heart Network evaluated chronic DCM patients with prospective echocardiographic and clinical data collection during an 18-month follow-up. Inclusion criteria were age <22 years and DCM disease duration >2 months. Patients requiring intravenous inotropic/mechanical support or listed status 1A/1B for transplant were excluded. Disease progression was defined as an increase in transplant listing status, hospitalization for heart failure, intravenous inotropes, mechanical support, or death. Predictors of disease progression were identified using Cox proportional hazards modeling and classification and regression tree analysis. Of the 127 patients, 28 (22%) had disease progression during the 18-month follow-up. Multivariable analysis identified older age at diagnosis, larger left ventricular (LV) end-diastolic M-mode dimension z-score, and lower septal peak systolic tissue Doppler velocity z-score as independent predictors of disease progression. Classification and regression tree analysis stratified patients at risk of disease progression with 89% sensitivity and 94% specificity based on LV end-diastolic M-mode dimension z-score ≥7.7, LV ejection fraction<39%, LV inflow propagation velocity (color M-mode) z-score <−0.28, and age at diagnosis ≥8.5 months. The authors conclude that in children with chronic stable DCM, a combination of diagnosis after late infancy and echocardiographic parameters of larger LV size and systolic and diastolic function predicted disease progression.
Arbour RB. Brain death: Assessment, controversy, and confounding factors. Critical Care Nurse 2013;33:27–48.
When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria. Clinical evaluation typically entails two consecutive formal neurological examinations to document total loss of consciousness and absence of brain stem reflexes and then apnea testing to evaluate carbon dioxide unresponsiveness within the brain stem. Confounding factors such as use of therapeutic hypothermia, high-dose metabolic suppression, and movements associated with complex spinal reflexes, fasciculations, or cardiogenic ventilator auto-triggering may delay initiation or completion of brain death protocols. Neurodiagnostic studies such as four-vessel cerebral angiography can rapidly document absence of blood flow to the brain and decrease intervals between onset of terminal brain stem herniation and formal declaration of death by neurological criteria. Intracranial pathophysiology leading to brain death must be considered along with clinical assessment, patterns of vital signs, and relevant diagnostic studies.
Cees DMR, Kerkof AJFM, van der Wal G, Onwuteaka-Philipsen BD. Symptoms, unbearability and the nature of suffering in terminal cancer patients dying at home: A prospective primary care study. BMC Family Pract 2013;14:201.
Primary care physicians provide palliative home care. In cancer patients dying at home in the Netherlands (45% of all cancer patients), euthanasia in about one out of every seven patients indicates unbearable suffering. Symptom prevalence, relationship between intensity of symptoms and unbearable suffering, evolvement of symptoms and unbearability over time, and quality of unbearable suffering were studied in end-of-life cancer patients in primary care. During a three-year period, 44 general practitioners recruited cancer patients estimated to die within six months. Every two months patients quantified intensity as well as unbearability of 69 symptoms with the State-of-Suffering-V (SOS-V). Overall unbearable suffering was also quantified. The five-point rating scale ranged from 1 (not at all) to 5 (cannot be worse). For symptoms assessed to be unbearable, the nature of the suffering was additionally investigated with open-ended questions. The final interviews were analyzed; for longitudinal evolvement also the pre-final interviews were analyzed. Symptom intensity scores 4 and 5 were defined to indicate high intensity. Symptom unbearability scores 4 and 5 were defined to indicate unbearable suffering. Two raters categorized the qualitative descriptions of unbearable suffering. Results demonstrated that out of 148 requested patients, 51% participated; 64 patients were followed up until death. The SOS-V was administered at least once in 60 patients (on average 30 days before death) and at least twice in 33 patients. Weakness was the most frequent unbearable symptom (57%). Pain was unbearable in 25%. Pain, loss of control over one's life, and fear of future suffering frequently were unbearable (89%–92%) when symptom intensity was high. Loss of control over one's life, vomiting, and not being able to do important things frequently were unbearable (52%–80%) when symptom intensity was low. Unbearable weakness significantly increased between pre-final and final interview. Physical suffering, loss of meaning and autonomy, feeling a burden, fear of future suffering, and frequent worrying occurred in patients with significant overall suffering. The authors conclude that weakness was the most prevalent unbearable symptom in an end-of-life primary care cancer population. Physical suffering, loss of meaning, and loss of autonomy more frequently occurred in patients who suffered unbearably overall.
Rief H, Heinhold RC, Petersen LC, et al. Neurological outcome after emergency radiotherapy in MSCC of patients with non-small cell lung cancer: A prospective trial. Radiation Oncol 2013;8:297.
The aim of this trial was to investigate neurological outcome after emergency radiation therapy (RT) in malignant spinal cord compression (MSCC) of nonsmall cell lung cancer (NSCLC) patients with acute neurological deficit. In this prospective, nonrandomized, pilot trial involving one medical center, 10 patients were treated from July 2012 until June 2013. After onset of neurological symptoms, RT was started within 12 hours. The neurological outcome was assessed at baseline, and six weeks after RT using the ASIA Impairment Scale (AIS). Results demonstrated that there was an improved neurological outcome in one patient (10%), one patient (10%) had a worsened outcome, and five patients (50%) a constant outcome after six weeks. Three patients (30%) died within the first six weeks following RT, and an additional four patients (40%) died within four months due to tumor progression. The authors conclude that in this group of NSCLC patients they were able to show that emergency RT in MSCC with acute neurological deficit had no considerable benefit in neurological outcome. Therefore, short course regime or best supportive care due to poor survival should be considered for these patients with additional distant metastases, while patients with a favorable prognosis may be candidates for long course RT.