Abstract
Rand KL, Banno DA, Shea AM, Cripe LD: Life and treatment goals of patients with advanced, incurable cancer. J Pain Symptom Manage 2016;24:2953–2962.
Goals of care conversations have been suggested as a strategy for helping patients with advanced cancer manage the uncertainty and distress associated with end-of-life care (EOLC). However, knowledge deficits about patient goals limit the utility of such conversations. The authors described the life and treatment goals of patients with incurable cancers, including goal values and expectancies. They examined the associations between paramount goals and patient prognosis, performance status, and psychological adjustment. Patients with advanced lung cancer, gastrointestinal cancer, or melanoma (N = 84) completed measures of prognosis for 12-month survival, hope, optimism, depression, and anxiety. Oncologists provided patient performance status and prognosis for 12-month survival. The authors conducted interviews with a subset of patients (N = 63), eliciting life and treatment goals, values, and expectancies. Results demonstrated that patient life goals resembled goals among healthy populations; whereas treatment goals were perceived as separate and more important. Cure and fight cancer emerged as the most important goals. Patients who valued cure the most had worse performance status and more depressive symptoms. Patients who valued fight cancer the most had worse self-prognosis, fewer treatment goals, and lower optimism. The authors conclude that patients with advanced cancer perceive treatment goals as separate from, and more important than, life goals. They hold optimistic expectancies for achieving their goals and for survival. Valuing cure highly may put patients at risk for experiencing psychological maladjustment.
Leung D, Angus JE, Sinuff T, et al.: Transitions to end-of-life care for patients with chronic critical illness: A meta-synthesis. Am J Hospice Palliat Med 2016 [Epub ahead of time]; DOI: 10.1177/1049909116649986.
Adults with chronic critical illness (CCI) frequently experience a terminal trajectory but receive varying degrees of palliation and EOLC in intensive care units (ICUs). Why palliation (over curative treatment) is not augmented earlier for patients with CCI in ICU is not well understood. The authors completed this study to identify the social structures that contribute to timely, context-dependent decisions for transition from acute care to EOLC for patients with CCI and their families. They conducted a meta-synthesis of qualitative and/or mixed-method studies that recruited adults with CCI, their families or close friends, and/or healthcare providers (HCPs) in an ICU environment. Results demonstrated that 5 studies reported data from 83 patients, 109 family members, and 57 HCPs across 5 institutions in Canada and the United States. Overall, we found that morally ambiguous social expectations of treatment tended to lock in HCPs to focus on prescriptive work of preserving life, despite pathways that could “open” access to augmenting palliation and EOLC. This process limited space for families' reflexivity and reappraisal of CCI as a phase liminal to active dying. Notably, EOLC mechanisms were informal and less visible. The authors conclude that the management of dying is one of the central tenets of ICUs. Their findings suggest that patients and families need help in negotiating meanings of this situation and in using mechanisms that allow reappraisal and permit understanding of CCI as a phase liminal to dying. Moreover, these mechanisms may paradoxically reduce the ambiguity of patients' future, allowing them to live more fully in the present.
Bosnjak SM, Dimitrijevic J, Djordjevic F: Cancer and chemotherapy-induced nausea and vomiting: A focus on olanzapine. Curr Opin Support Palliat Care 2016;10:180–188.
The purpose of this review is to critically present evidence supporting the use of olanzapine, an atypical antipsychotic, as an antiemetic for cancer and chemotherapy-induced nausea and vomiting (CINV). Two phase III clinical studies demonstrated superior efficacy of olanzapine than the neurokinin-1 receptor antagonists (NK1RA) for substance P (aprepitant, fosaprepitant) in the prevention of nausea after highly emetogenic chemotherapy. Olanzapine is inexpensive and the replacement of NK1RA with olanzapine can reduce the costs of the prevention of CINV. The addition of olanzapine to aprepitant-containing combination regimens for the prevention of CINV was also investigated, and has the potential to further improve the prevention of CINV after highly emetogenic chemotherapy or moderately emetogenic chemotherapy, without substantial increase in costs. In the treatment of uncontrolled (“breakthrough”) CINV, olanzapine was more effective than metoclopramide. Existing clinical data also support the use of olanzapine to relieve a cluster of gastrointestinal symptoms in patients with advanced cancer (chronic nausea, vomiting, and anorexia). When used in cancer patients, olanzapine is well tolerated, with sedation being the major dose-limiting side effect. The authors conclude that existing data from clinical trials justify further research of the role of olanzapine in the prevention of CINV. Olanzapine may be used instead of or in addition to NK1RA in the preventive antiemetic regimens. Olanzapine-containing preventive regimens may provide better nausea control after chemotherapy. When used instead of NK1RA, it may also provide substantial reduction in costs of CINV prevention. In patients with advanced cancer, olanzapine was effective against a cluster of gastrointestinal symptoms (nausea, vomiting, and anorexia). The use of olanzapine as an antiemetic for CINV or to relieve nausea, vomiting, and anorexia in palliative care is currently off-label.
Nicholas DB, Beanune L, Barrera M, et al.: Examining the experiences of fathers of children with a life-limiting illness. J Soc Work End of Life Palliat Care 2016;12:126–144.
Families who have a child diagnosed with a life-limiting illness (LLI) face substantial challenges resulting from the complexity and devastating impact of the condition and potential closeness of death. The experiences of fathers of a child with LLI have been understudied; therefore, this study explored the stresses, experiences, and strategies of these fathers, including their perceptions about support needs. Based on grounded theory, in-depth semistructured interviews were conducted with 18 fathers of children with LLI. Six fathers had experienced the death of their child. The overarching themes were stresses, means of coping, and perceived needs for support. In general, fathers in this study struggled relative to discursive and internalized notions of fathers as providers and protectors for their children, combined with an inability to ease their child's vulnerability to LLI. Participants were engaged in the care of their child with LLI, but several felt marginalized by HCPs in care planning and staff/family communication. Some fathers recognized and valued their support network while others had few supports. Some described personal growth and desired to help other fathers. Practice implications and recommendations include renewed application of family-centered care, overcoming presumptions about fathers' roles and recognizing the impact of LLI beyond physical health.
Harrison A, Smith R, Champagne M, et al.: Implementation of a delirium assessment protocol in an inpatient hospice setting. J Hosp Palliat Nurs 2016;18:227–232.
The purpose of this quality improvement project was to improve the recognition of delirium in an inpatient hospice setting through the use of the Confusion Assessment Method (CAM) by staff nurses. After receiving education on the CAM, staff nurses used the tool to assess for the presence of delirium among adult patients admitted for hospice care. Those who screened positive were further assessed for reversible causes of the syndrome with CHIMBOP (constipation, hypovolemia/hyponatremia, infection, medications, bladder catheter or obstruction, oxygen deficiency, and pain). After project implementation over eight weeks, nurses completed an ease-of-use survey for the tool. Ninety-two percent of adult hospice patients eligible for delirium assessment were assessed by staff nurses. Of these, 36% screened positive for delirium. The ease-of-use survey indicated that ∼30% of nurses strongly agreed or agreed that the CAM and CHIMBOP added value to their nursing practice. The results of this project indicated that nursing staff are able to assess for delirium in the inpatient hospice setting but most do not agree that the CAM and CHIMBOP add value in their practice.