Abstract
van Soest-Poortvliet MC, van der Steen JT, de Vet HCW, et al.: Comfort goal of care and end-of-life outcomes in dementia: A prospective study. Palliat Med 2015. [E-pub ahead of print.]
Many people with dementia die in a nursing home, an environment where a comfort care goal may be beneficial. That said, little research has examined the relationship between care goals and outcome. The aim of this study was to investigate whether family satisfaction with end-of-life care and quality of dying was associated with whether or not dementia patients have a comfort goal shortly after admission. Prospective data was collected from 28 long-term care facilities. The authors included 148 patients who died after prospective follow-up. The main outcomes of the study were family satisfaction (End-of-Life in Dementia–Satisfaction with Care scale; range: 10–40) and quality of dying (End-of-Life in Dementia–Comfort Assessment in Dying scale; range: 14–42). The authors performed generalized estimating equations regression analyses to analyze whether these outcomes were associated with a comfort goal established shortly after admission compared with another or no care goal as reported by the physician. Results demonstrated that families of studied patients were more satisfied with end-of-life care when a comfort goal was established shortly after admission. However, this pattern was noted only for patients who died within six months of admission. Interestingly, for quality of dying, no such association was found. The authors conclude that they found that family satisfaction with care was related to a comfort care goal shortly after admission, but quality of dying was not. They suggest that establishing a comfort goal at an early stage may be important to the family.
Rowbottom L, Pasetka M, McDonald R, et al.: Efficacy of granisetron and aprepitant in a patient who failed ondansetron in the prophylaxis of radiation induced nausea and vomiting: A case report. Ann Palliat Med 2015. [E-pub ahead of print.]
Radiotherapy-induced nausea and vomiting (RINV) is a toxicity that occurs in 40% to 80% of individuals who receive radiation treatment. Current guidelines recommend 5-hydroxytryptamine3 receptor antagonists (5-HT3 RAs) for prophylaxis of RINV for moderate and highly emetogenic radiotherapy; however, certain patients may suffer from RINV despite prophylaxis. This report details the case of a 47-year-old female with extensive bony involvement to the spine from breast cancer presenting with lower back pain. To palliate her symptoms, the patient underwent a course of irradiation to the lumbar spine and was prescribed ondansetron as an antiemetic. However, she experienced severe nausea and emesis and was subsequently switched to granisetron and aprepitant. The patient completed the remainder of the radiation treatment with no further emesis and minimal nausea, representing the first documented success of granisetron and aprepitant for RINV after failure on ondansetron. The authors conclude that in chemotherapy, switching 5-HT3 RAs after failure on the first is successful in preventing chemotherapy-induced nausea and vomiting (CINV), yet this has not been previously reported in radiation. In this patient, granisetron and aprepitant were successful in substantially reducing nausea and preventing further emesis, and may represent an alternative antiemetic regimen for RINV prophylaxis and salvage.
Kelley ML: Death in long-term care: A brief report examining factors associated with death within 31 days of assessment. Palliat Care Research Treat 2015;9:1–5.
Research indicates that residents newly admitted to long-term care facilities are at a higher risk of mortality. The purpose of this study was to examine the risk of mortality within 31 days of assessment among long-term care residents using administrative health data. The authors utilized administrative data to examine the risk of mortality within 31 days of assessment among all long-term care residents in Ontario over a 12-month period. Data were provided by the Canadian Institute for Health Information using the Continuing Care Reporting System (CCRS), Discharge Abstract Database (DAD), and the National Ambulatory Care Reporting System (NACRS). Results demonstrated that a number of diagnoses and health conditions predict death within 31 days. Diagnoses that hold an increased risk of mortality include pulmonary disease, cancer, and heart disease. Health conditions that lead to an increased likelihood of death include weight loss, dehydration, and shortness of breath. The presence of a fall within the last 30 days was also related to a higher risk of mortality. The authors conclude that residents in long-term care facilities who lose weight, have persistent problems with hydration, and suffer from shortness of breath are at particular risk of death. Interestingly, the presence of advance directives also predicts death within 31 days of assessment.
Lindell KO, Liang ZL, Hoffman LA, et al.: Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest 2015;147:423–429.
Palliative care, if integrated early, may reduce symptom burden in patients with idiopathic pulmonary fibrosis (IPF). However, limited information exists on timing and clinical practice. The purpose of this study was to describe the time course of events prior to death in patients with IPF managed at a specialty center with a focus on location of death and timing of referral for palliative care. Data were retrospectively extracted from the health system's data repository and obituary listings. The sample included all decedents, excluding lung transplant recipients, who had their first visit to the center between 2000 and 2012. Results demonstrated that median survival for 404 decedents was three years from diagnosis and one year from first center visit. Of 277 decedents whose location of death could be determined, >50% died in the hospital (57%). Only 38 (13.7%) had a formal palliative care referral and the majority (71%) were referred within one month of their death. Decedents who died in the academic medical center ICU were significantly younger than those who died in a community hospital ward (P=0.040) or hospice (P=0.001). The authors conclude that the majority of patients with IPF died in a hospital setting and only a minority received a formal palliative care referral, and when referral did occur, it occurred late in the disease. These findings indicate the need to study adequacy of end-of-life management in IPF and promote earlier discussion and referral to palliative care.
Lin JJ, Gallagher EJ, Sigel K, et al.: Survival of patients with stage IV lung cancer with diabetes treated with metformin. Am J Respir Crit Care 2015;191:448–454.
Prior studies have shown an anticancer effect of metformin in patients with breast and colorectal cancer. However, it is unclear whether metformin has a mortality benefit in lung cancer. The purpose of this study was to compare overall survival of patients with diabetes with stage IV non–small cell lung cancer (NSCLC) taking metformin versus those not on metformin. Using data from the Surveillance, Epidemiology, and End Results registry linked to Medicare claims, the authors identified 750 patients with diabetes 65–80 years of age diagnosed with stage IV NSCLC between 2007 and 2009. The authors used propensity score methods to assess the association of metformin use with overall survival while controlling for potential confounders. Results demonstrated that, overall, 61% of patients were on metformin at the time of lung cancer diagnosis. Median survival in the metformin group was five months, compared with three months in patients not treated with metformin (P<0.001). Propensity score analyses showed that metformin use was associated with a statistically significant improvement in survival after controlling for sociodemographics, diabetes severity, other diabetes medications, cancer characteristics, and treatment. The authors conclude that metformin is associated with improved survival among patients with diabetes with stage IV NSCLC, suggesting a potential anticancer effect. They also suggest that further research should evaluate plausible biologic mechanisms and test the effect of metformin in prospective clinical trials.