Abstract
Rush B, Hertz P, Bond A, et al.: Utilization of palliative care in patients with end-stage chronic obstructive pulmonary disease on home oxygen: National trends and barriers to care in the United States. Chest 2016;pii:S0012-3692(16)52413-1
The objective of this study was to investigate the use of palliative care (PC) in patients with end-stage chronic obstructive pulmonary disease (COPD) on home oxygen hospitalized for an exacerbation. A retrospective nationwide cohort analysis utilizing the Nationwide Inpatient Sample (NIS) was completed. All patients >18 years of age with a diagnosis of COPD on home oxygen admitted for an exacerbation were included. Results demonstrated that 55,208,382 hospitalizations from the 2006 to 2012 NIS samples were examined. There were 181,689 patients with COPD on home oxygen admitted for an exacerbation, 3145 (1.7%) patients also had a PC contact. There was a 4.5-fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%, p < 0.01). Patients receiving PC consultations compared with those who did not were older (75.0 years standard deviation [SD] 10.9 vs. 70.6 years SD 9.7, p < 0.01), had longer hospitalizations (4.9 days), and more likely to die in hospital (32.1% vs. 1.5%, p < 0.01). Race was significantly associated with referral to PC, with white patients referred more often than minorities (p < 0.01). Factors associated with PC referral were age, metastatic cancer, nonmetastatic cancer, invasive mechanical ventilation, noninvasive mechanical ventilation, and do-not-resuscitate order status. The authors conclude that the use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of end-stage COPD patients admitted with an exacerbation.
Odejide OO, Cronin AM, Condron NB, et al.: Barriers to quality end-of-life care for patients with blood cancers. J Clin Oncol 2016 [Epub ahead of print]; DOI: 10.1200/JCO.2016.67.8177.
Patients with blood cancers have been shown to receive suboptimal care at the end of life (EOL) when assessed with standard oncology quality measures (e.g., no chemotherapy ≤14 days before death). As they were developed primarily for solid tumors, it is unclear whether these measures are appropriate for patients with hematologic malignancies. Moreover, barriers to high-quality EOL care for this specific patient population are largely unknown. In 2015, the authors asked a national cohort of hematologic oncologists about the acceptability of eight standard EOL quality measures. Building on prior qualitative work, they prespecified that measures achieving agreement among at least 55% of respondents would be considered acceptable. They also explored perspectives regarding barriers to quality EOL care. Results demonstrated that the authors received 349 surveys (response rate = 57.3%). Six of the standard measures met the threshold of acceptability and four were acceptable to >75% of respondents: hospice admission >7 days before death, no chemotherapy ≤14 days before death, no intubation in the last 30 days of life, and no cardiopulmonary resuscitation in the last 30 days of life. The highest ranked barriers to quality EOL care reported were “unrealistic patient expectations” (97.3%), “clinician concern about taking away hope” (71.3%), and “unrealistic clinician expectations” (59.0%). The authors conclude that in this large national cohort of hematologic oncologists, standard EOL quality measures were highly acceptable. The top barrier to quality EOL care reported was unrealistic patient expectations, which may be best addressed with more timely and effective advance care discussions.
Gammal RS, Crews KR, Haidar CE, et al.: Pharmacogenetics for safe codeine use in sickle cell disease. Pediatrics 2016 [Epub ahead of print]; DOI: 10.1542/peds.2015-3479.
After postoperative deaths in children who were prescribed codeine, several pediatric hospitals have removed it from their formularies. These deaths were attributed to atypical cytochrome P450 2D6 (CYP2D6) pharmacogenetics, which is also implicated in poor analgesic response. Because codeine is often prescribed to patients with sickle cell disease and is now the only Schedule III opioid analgesic in the United States, the authors implemented a precision medicine approach to safely maintain codeine as an option for pain control. In this article, they describe the implementation of pharmacogenetics-based codeine prescribing that accounts for CYP2D6 metabolizer status. Clinical decision support was implemented within the electronic health record to guide prescribing of codeine with the goal of preventing its use after tonsillectomy or adenoidectomy and in CYP2D6 ultra-rapid and poor metabolizer (high-risk) genotypes. As of June 2015, CYP2D6 genotype results had been reported for 2468 unique patients. Of the 830 patients with sickle cell disease, 621 (75%) had a CYP2D6 genotype result, 7.1% were ultrarapid or possible ultrarapid metabolizers, and 1.4% were poor metabolizers. Interruptive alerts recommended against codeine for patients with high-risk CYP2D6 status. None of the patients with an ultrarapid or poor metabolizer genotype were prescribed codeine. Using genetics to tailor analgesic prescribing retained an important therapeutic option by limiting codeine use to patients who could safely receive and benefit from it. The author's efforts represent an evidence-based, innovative medication safety strategy to prevent adverse drug events, which is a model for the use of pharmacogenetics to optimize drug therapy in specialized pediatric populations.
Willmott L, White B, Gallois C, et al.: Reasons doctors provide futile treatment at the end of life: A qualitative study. J Med Ethics 2016;42:496–503.
Futile treatment, which by definition cannot benefit a patient, is undesirable. The aim of this study from three large tertiary public hospitals in Brisbane, Australia, was to investigate why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life. Ninety-six doctors from emergency, intensive care, PC, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine, and medical administration departments participated in the study. Participants were recruited using purposive maximum variation sampling. Results demonstrated that doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation toward curative treatment, discomfort, or inexperience with death and dying, concerns about legal risk, and poor communication skills. Then there were the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty, and lack of information about patient wishes. Also noted were hospital factors including a high degree of specialization, the availability of routine tests and interventions, and organizational barriers to diverting a patient from a curative to a palliative pathway. Doctors believed that family or patient request and doctors being locked into a curative role were the main reasons for futile care. The authors conclude that doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the EOL, educating the community about the limits of medicine, and the need to plan for death and dying, and structural reform at the hospital level.
Morgan T, Williams LA, Trussardi G, Gott M: Gender and family caregiving at the end-of-life in the context of old age: A systematic review. Palliat Care 2016;30:616–624.
As societies age and governments attempt to manage within constrained health budgets by moving care into community settings, women will be called upon to provide more PC in old age. However, little is known about gendered disparities for caregivers of people over the age of 65 years. The authors of this study attempted to identify and synthesize the empirical literature between 1994 and 2014 that focuses on gender and family caregiving for people over the age of 65 years with a life-limiting illness. This study was a systematic review of qualitative and quantitative studies conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. Supplemental review used a novel feminist quality appraisal framework. Results demonstrated that of 19 studies identified, 9 presented thorough gender analyses. Gender themes included why people care, how they care, and the consequences of providing care. Women caregivers experienced a greater degree of mental and physical strain than their male counterparts. This was linked to societal expectation that women should provide a greater degree of care at the EOL for family members. The authors conclude that palliative family caregiving for older adults is gendered. Gender affects why people care and the consequences of providing care. PC literature needs to incorporate a greater gender focus for future research and policy makers need to be aware of the gendered ramifications of providing more PC in the community.