Abstract
Singleton PA, Moss J, Karp DD, et al.: The mu opioid receptor: A new target for cancer therapy? Cancer 2015;121:2681–2688.
Mu opioids are among the most widely used drugs for patients with cancer with both acute and chronic pain as well as in the perioperative period. Several retrospective studies have suggested that opioid use might promote tumor progression and as a result negatively impact survival in patients with advanced cancer; however, in the absence of appropriate prospective validation, any changes in recommendations for opioid use are not warranted. In this review the authors present preclinical and clinical data that support their hypothesis that the mu opioid receptor is a potential target for cancer therapy because of its plausible role in tumor progression. The authors also propose the hypothesis that peripheral opioid antagonists such as methylnaltrexone, which reverses the peripheral effects of mu opioids but maintains centrally mediated analgesia and is approved by the U.S. Food and Drug Administration for the treatment of opioid-induced constipation, can be used to target the mu opioid receptor.
Leung AK, Nayyar D, Sachdeva M, et al.: Chronically homeless persons' participation in an advance directive intervention: A cohort study. Palliat Med 2015;29:746–755.
Chronically homeless individuals have high rates of hospitalization and death; however, they may benefit from the completion of advance directives. In this study the authors attempted to determine the rate of advance directive completion by using a counselor guided intervention, identifying characteristics associated with advance directive completion, and describing end-of-life care preferences in a group of chronically homeless individuals. A total of 205 residents of a shelter in Canada for homeless men (89.1% of those approached) participated from April to June 2013. They completed a survey and were offered an opportunity to complete an advance directive with a trained counselor.
Results demonstrated that the duration of homelessness was ≥12 months in 72.8% of participants, and 103 participants (50.2%) chose to complete an advance directive. Sociodemographic characteristics, health status, and health care use were not associated with completion of an advance directive. Participants were more likely to complete an advance directive if they reported thinking about death on a daily basis, believed that thinking about their friends and family was important, or reported knowing their wishes for end-of-life care but had not told anyone about these wishes. Among individuals who completed an advance directive, 61.2% named a substitute decision maker, and 94.1% expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest if there was a chance of returning to their current state of health. The authors conclude that a counselor guided intervention can achieve a high rate of advance directive completion among chronically homeless persons, and that most participants expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest.
Dionisio R, Giardini A, De Cata P, et al.: Diabetes management in end of life: A preliminary report stemming from clinical experience. Am J Hosp Palliat Med 2015;32:588–593.
The increasing coexistence of cancer and diabetes mellitus within the elderly population requires specific palliative care skills on diabetes treatment. The authors report their experience with diabetes management in a palliative care setting. In their retrospective three-year activity sample (n = 563), 27.2% of patients had a diagnosis of diabetes mellitus; 80% had cancer, whereas 20% had a main diagnosis of other severe chronic diseases. As to the presence/absence of diabetes mellitus, no differences emerged in the examined clinical indicators and global survival, with the exception of body mass index and days of hospitalization. At analysis, the Barthel index and palliative prognostic index are the only parameters significantly related to death. Even if diabetes mellitus does not seem to modify prognosis, it significantly influences the health care burden and team engagement.
Ricket A, Mateyoke G, Vallabh M, et al.: A pilot evaluation of a hydromorphone dose substitution policy and the effects on patient safety and pain management. J Pain Palliat Care Pharmacother 2015;29:120–124.
Hydromorphone is a potent opioid analgesic commonly used in the hospital setting for the management of acute pain. Initial dose recommendations range from 0.1 to 2.0 mg of hydromorphone for opioid-naïve patients. This creates a challenge to optimally dose hydromorphone in opioid-naïve patients with the goals of avoiding opioid toxicities while also providing adequate pain management. In order to minimize the incidence of opioid toxicity, a community hospital implemented a dose substitution hydromorphone policy that allows practitioners to automatically use a lower dose of hydromorphone within criteria limits. This pilot study was conducted to assess if the implementation of a low-dose hydromorphone protocol reduces the incidence of opioid toxicity while maintaining adequate pain management. This retrospective, observational, single-center cohort study examined hospitalized patients treated with hydromorphone between January 2013 and November 2013. Inpatients over 18 years of age who received hydromorphone were included in the study. The primary outcome of the study was the incidence of opioid toxicity. The secondary outcome of the study was adequate pain management. The results of this study demonstrated no difference in opioid toxicity; however, patients required less per day hydromorphone and other opioids while still adequately managing their pain.
Black K, Csikai E: Dying in the age of choice. J Soc Work End Life Palliat Care 2015;11:27–49.
Due to the unprecedented increase in U.S. aging demographics, many more people than ever are living longer and reaching older ages. However, a longer life is not necessarily a better life, as the vast majority will face a period of deteriorating health prior to death. Although notable efforts have been underway that are designed to improve the end-of-life experience, increasing numbers of individuals express a desire and/or act on an intent to end their lives precipitously. Though still limited, the options to actively participate in their own deaths are growing. Requests for a hastened death can occur among people of all ages and include those with advanced illness as well as others wanting to die due to unbearable suffering. This article provides an overview of the ongoing discourse about the experience of dying faced by many older adults, including aspects frequently associated with “a good death.” The limitations of established practices that seek to provide a “better” dying experience are identified, followed by discussion of the growing availability of alternative options. Reflective considerations are presented to guide practice regarding the changing landscape surrounding options in dying.
Bushor L, Mayola R: Symptom management of chronic illness in the adult outpatient setting. J Hosp Palliat Care Nurs 2015;17:285–290.
Veterans, as a distinct population, experience high rates of recidivism, with 75% of those older than 65 years having symptomatic chronic illness. Five diagnoses—congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dementia, and cancer—account for 25% of health care visits associated with high rates of recidivism. A convenience sample of 37 veterans with advanced chronic illness from one rural home-based primary care clinic was evaluated. All subjects had at least one of the five listed diagnoses. One-way repeated-measures analysis of variance was used to evaluate retrospective and prospective data at 30, 60, and 90 days before/after implementation of palliative care modalities. Congestive heart failure and chronic obstructive pulmonary disease accounted for 53% of diagnoses. Sixty-five percent had two or more diagnoses. By day 90 after palliative management, there were 122 fewer emergency department/hospital days (P < 0.01) with an estimated cost avoidance of $220,000. Initiating palliative care early in the trajectory of symptomatic illness reduces recidivism and overall costs of care through management of symptoms and focusing on patient/caregiver directed goals for improving life. In addition, further studies are needed to evaluate symptomatic, chronic illness for diseases outside of cancer.
Hurria A, Levit LA, Dale W, et al.: Improving the evidence base for treating older adults with cancer: American Society of Clinical Oncology statement. J Clin Oncol 2015. (E-pub ahead of print.)
The American Society of Clinical Oncology (ASCO) convened a subcommittee to develop recommendations on improving the evidence base for treating older adults with cancer in response to a critical need identified by the Institute of Medicine. Older adults experience the majority of cancer diagnoses and deaths and make up the majority of cancer survivors; and they are also the fastest growing segment of the U.S. population. However, the evidence base for treating this population is sparse, because older adults are underrepresented in clinical trials, and trials designed specifically for older adults are rare. The result is that clinicians have less evidence on how to treat older adults, who represent the majority of patients with cancer. Clinicians and patients are forced to extrapolate from trials conducted in younger, healthier populations when developing treatment plans. This has created a dearth of knowledge regarding the risk of toxicity in the average older patient and about key endpoints of importance to older adults. ASCO makes five recommendations to improve evidence generation in this population: (1) Use clinical trials to improve the evidence base for treating older adults with cancer; (2) Leverage research designs and infrastructure for generating evidence on older adults with cancer; (3) Increase U.S. Food and Drug Administration authority to incentivize and require research involving older adults with cancer; (4) Increase clinicians' recruitment of older adults with cancer to clinical trials, and (5) Use journal policies to improve researchers' reporting on the age distribution and health risk profiles of research participants.