Abstract
Friedrichsen M, Hairadinovic Y, Jakobsson M, et al.: Palliative care consultation team on acute wards—An intervention study with pre-post comparisons. Support Care Cancer 2017;25:371–380.
There is little evidence regarding primary healthcare team members' perceptions concerning palliative care consultation team (PCCT) and palliative care (PC) issues on their own wards. In this study, the authors attempted to determine whether a PCCT can influence and change primary healthcare team members' perceptions regarding the PC at the end of life they are providing to patients in their own acute wards. The intervention was a PCCT visiting surgical and internal medicine wards in one year. We used a quasi-experimental design with pre-post-testing, measuring at baseline, and after one year's intervention. A questionnaire was answered by all primary healthcare team members in three acute wards. Results demonstrated that a total of 252 team members (pre- and post-intervention n = 132/n = 120) participated in the study. Overall, 11 of the 12 statements scored significantly higher after the intervention than before. Responses varied significantly between different professions and depending on the number of dying patients cared for during the past month. The five with the highest Wald values were as follows: the presence of a break point dialogue with a patient, where the changed aim and focus of care were discussed; early detection of impending death; adequate symptom relief; and psychological and existential issues. The authors conclude that it is possible to change perceptions about end-of-life care in primary healthcare team members on acute wards. PCCTs should be a natural part wherever dying patients are cared for.
Knies AK, Hwang DY: Palliative care practice in neurocritical care. Semin Neurol 2016;36:631–641.
Many neurocritically ill patients and their families have high amounts of PC needs, and multiple professional societies relevant to neurocritical care have released consensus statements on meeting PC needs in neuroscience intensive care units. In this review, the authors discuss the ongoing debate regarding what model of PC delivery is optimal, focus on the process of shared decision making during goals-of-care discussions, and briefly comment on transitions from intensive care to comfort care. Regardless of an institution's model of PC practice, every neurocritical care clinician should possess core competencies necessary to provide basic, integrative PC for neurocritically ill patients. Given the high proportion of neurocritically ill patients who lack decision-making capacity, communication skills that enable clinicians to facilitate shared decision making with patients' surrogates are of particular relevance, especially when the limitation of life support is in the discussion. High-quality decision aids to assist neurocritical care teams and surrogate decision makers during common goals-of-care discussions may have the potential for further promotion of best PC practices.
Koncicki HM, Unruh M, Schell JO: Pain management in CKD: A guide for nephrology providers. Am J Kidney Dis 2016 [Epub ahead of print]; DOI: 10.1053/j.ajkd.2016.08.039.
Although pain is one of the most commonly experienced symptoms by patients with chronic kidney disease, it is under-recognized, the severity is underestimated, and the treatment is inadequate. Pain management is one of the general primary PC competencies for medical providers. This review provides nephrology providers with basic skills for pain management. These skills include recognition of types of pain (nociceptive and neuropathic) syndromes and appropriate history-taking skills. Through this history, providers can identify clinical circumstances in which specialist referral is beneficial, including those who are at high risk for addiction, at risk for adverse effects to medications, and those with complicated care needs such as patients with a limited prognosis. Management of pain begins with the development of a shared treatment plan, identification of appropriate medications, and continual follow-up and assessment of efficacy and adverse effects. Through adequate pain management, providers can positively affect the health of individual patients and the performance of healthcare systems.
Wu CC, Hsu TW, Chang CM, et al. Palliative chemotherapy affects aggressiveness of end-of-life care. Oncologist 2016 [Epub ahead of print]; DOI: 10.1634/theoncologist.2015-0445.
Although palliative chemotherapy during end-of-life care is used for relief of symptoms in patients with metastatic cancer, chemotherapy may lead to more aggressive end-of-life care and less use of hospice service. In this population-based study, the authors attempted to determine the association between palliative chemotherapy and aggressiveness of end-of-life care. Using the National Health Insurance Research Database of Taiwan, the authors identified 49,920 patients with metastatic cancer who underwent palliative chemotherapy from January 1, 2009, to December 31, 2011. Patients who received chemotherapy two to six months before death were included. Aggressiveness of end-of-life care was examined by previously reported indicators. Cardiopulmonary resuscitation and endotracheal tube intubation were included as indicators of aggressive end-of-life care. The association between palliative chemotherapy and hospice care was studied. Results demonstrated that palliative chemotherapy was associated with more aggressive treatment. After adjustment for patient age, sex, Charlson Comorbidity Index score, cancer group, primary physician's specialty, postdiagnosis survival, hospital characteristics, hospital caseload, urbanization, and geographic regions, more than one emergency room visit (p < 0.001), more than one intensive care unit admission (p < 0.001), and endotracheal intubation (p = 0.02) during end-of-life care were significantly more common in patients receiving palliative chemotherapy. Patients who did not receive palliative chemotherapy received more hospice care in the last six months of life (p < 0.001). The authors conclude that although the decision to initiate palliative chemotherapy was made several months before death, this study showed that palliative chemotherapy was associated with more aggressive end-of-life care, including more emergency room visits and intensive care unit admissions and endotracheal intubation. The patients who received palliative chemotherapy received less hospice service toward the end of life.
Wentlandt K, Dall'Osto A, Freeman N, et al. The transplant palliative care clinic: An early palliative care model for patients in a transplant program. Clin Transplant 2016 [Epub ahead of print]; DOI: 10.1111/ctr.12838.
Although patients within a transplant program are awaiting or have received disease-modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized PC services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing PC resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory PC for these patients and there have been no descriptions of programs delivering such care in the medical literature. The authors outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated PC to patients awaiting and receiving organ transplantation.
Raj VS, Silver JK, Pugh TM, Fu JB. Palliative care and physiatry in the oncology care spectrum: An opportunity for distinct and collaborative approaches. Phys Med Rehabil Clin N Am 2017;28:35–47.
As cancer evolves from a terminal illness to a chronic medical condition, so too does the view of clinical services. PC and physical medicine and rehabilitation (PM&R) will increase in acceptance because they provide a valuable resource. The overarching theme is improving cancer-related symptoms or treatment-related side effects, improving patient health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision making. Managing symptom burden may improve therapy participation/performance. PM&R and PC departments are well equipped to develop patient-centered care protocols, and could play an important role in developing a universal measure of performance status.
Arnet I, Schacher S, Balmer E, et al. Poor adhesion of fentanyl transdermal patches may mimic end-of-dosage failure after 48 hours and prompt early patch replacement in hospitalized cancer pain patients. J Pain Res 2016;9:993–999.
Renewal of fentanyl transdermal patch (transdermal therapeutic system [TTS]) should occur every three days (72 hours) according to the manufacturer's guidelines. Some studies mentioned patients reporting end-of-dose failure, and thus, some authors recommend shortening the interval of application to two days (48 hours). However, reasons for early replacement are mostly unknown. The objectives of this study were to assess the prevalence of early replacement of fentanyl TTS in a cancer center in Basel, Switzerland, and to assess the reasons for early replacement in stationary patients. The authors retrieved all fentanyl TTS administered in a cancer center in Basel, Switzerland, between November 11, 2011, and January 31, 2015, from the electronic medical database. Results demonstrated that a total of 739 patients (mean age 71.4 ± 11.5 years, 55% women) were administered 2250 fentanyl TTS (dosage 6–500 μg/h). Most replacements occurred after 72 hours (61.6%) and a few after 48 hours (7.4%). Patients with early replacement after 48 hours were significantly younger (63.8 years vs. 71.5 years, p < 0.001) and obtained higher mean dosages of fentanyl TTS (89 μg/h vs. 44.1 μg/h, p < 0.001) and rescue medication (calculated as oral morphine equivalent in milligrams: 185.1 mg vs. 39.6 mg during the first 24 hours after replacement, p < 0.001). No pharmacological rationale for early replacement was observed. According to 57 physicians, nurses, and pharmacists, the most often reasons for early TTS replacement were end-of-dosage pain (41.4%) and poor adhesion (31.4%). The authors conclude that in the absence of any physiological, pharmacological, or environmental reasons recorded in the database to explain an early replacement of fentanyl TTS, skin adhesion problems may point practical reasons and mimic end-of-dosage failure.
Lotz JD, Daxer M, Jox RJ, et al. “Hope for the best, prepare for the worst”: A qualitative interview study on parents' needs and fears in pediatric advance care planning. Palliat Med 2016. [Epub ahead of print]; pii: 0269216316679913.
Pediatric advance care planning is advocated by healthcare providers because it may increase the chance that patient and/or parent wishes are respected and thus improve end-of-life care. However, as end-of-life decisions for children are particularly difficult and charged with emotions, physicians are often afraid of addressing pediatric advance care planning. The authors attempted to investigate parents' views and needs regarding pediatric advance care planning. They performed a qualitative interview study with parents of children who had died from a severe illness that included semistructured interviews with 11 parents of 9 children. Maximum variation was sought regarding the child's illness, age at death, care setting, and parent gender. Results demonstrated that parents find it difficult to engage in pediatric advance care planning but consider it important. They argue for a sensitive, individualized, and gradual approach. Hope and quality-of-life issues are primary. Parents have many nonmedical concerns that they want to discuss. Written advance directives are considered less important, but medical emergency plans are viewed as necessary in particular cases. Continuity of care and information should be improved through regular pediatric advance care planning meetings with the various care providers. Parents emphasize the importance of a continuous contact person to facilitate pediatric advance care planning. The authors conclude that despite a need for pediatric advance care planning, it is perceived as challenging. Needs-adjusted content and process and continuity of communication should be a main focus in pediatric advance care planning. Future research should focus on strategies that facilitate parent engagement in pediatric advance care planning to increase the benefit for the families.