Abstract
El-Jawahri A, LeBlanc TW, Burns E, et al. What do transplant physicians think about palliative care? A national survey study. Cancer 2018 [E-pub ahead of print]; https://doi.org/10.1002/cncr.31709.
Despite its established benefits, palliative care (PC) is rarely utilized for hematopoietic stem cell transplant (HSCT) patients. In this study, the authors sought to examine transplant physicians' perceptions of PC. The authors conducted a cross-sectional survey of transplant physicians recruited from the American-Society-for-Blood-and-Marrow-Transplantation. Using a 28-item questionnaire adapted from prior studies, they examined physicians' access to PC services, and perceptions of PC. They computed a composite score of physicians' attitudes about PC (mean = 16.9, SD = 3.37) and explored predictors of attitudes using a linear mixed model. A total of 277 out of 1005 (28%) eligible physicians completed the questionnaire. Results demonstrated that the majority (76%) stated that they trust PC clinicians to care for their patients, but 40% felt that PC clinicians do not have enough understanding to counsel HSCT patients about their treatments. Most endorsed that when patients hear the term PC, they feel scared (82%) and anxious (76%). Nearly half (46%) reported that the service name “palliative care” is a barrier to utilization. Female gender (p = 0.024), having <10 years of clinical practice (p = 0.004), and perceived quality of PC services (p < 0.001) were all associated with a more positive attitude toward PC. Physicians with a higher sense of ownership over their patients' PC issues (p < 0.001) were more likely to have a negative attitude toward PC. The authors conclude that the majority of transplant physicians trust PC, but have substantial concerns about PC clinicians' knowledge about HSCT and patients' perception of the term “palliative care.” The suggested interventions are needed to promote collaboration, improve perceptions, and enhance integration of PC for HSCT recipients.
Christian KM, Aoun SM, Breen LJ. How religious and spiritual beliefs explain prolonged grief disorder symptoms. Death Studies 2018 [E-pub ahead of print]; https://doi.org/10.1080/07481187.2018.1469054.
This study investigated the importance of religious and spiritual beliefs in daily life in explaining prolonged grief disorder (PGD) symptomatology. Participants were 588 bereaved adults who completed a questionnaire. The importance of spiritual beliefs in daily life explained a small to medium significant 3% of variance in PGD symptoms, but religious beliefs in daily life did not. The authors suggest that individuals who placed moderate importance on spiritual beliefs in their daily life may experience more intense grief.
Brassfield BR, Mishra M, Buchbinder M. Responding to requests for aid-in-dying: Rethinking the role of conscience. Narrative Inquiry in Bioethics 2018 [E-pub ahead of print]; DOI:10.1353/nib.0.0002.
This case study illustrates the complex role that a physician's conscience can play in end-of-life care. The authors examined a case from Vermont in which a terminally ill patient requested aid-in-dying from her primary care physician under the state's “Patient Choice and Control at End of Life” Act (Act 39). The physician felt conflicted: she was opposed to prescribing death-hastening medication but did not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. This analysis highlights the interplay of conflicting values that inform the physician's engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.
Trowbridge A, Walter JK, McConathey E, et al. Modes of death within a children's hospital. Pediatrics 2018 [E-pub ahead of print]; DOI:10.1542/peds.2017-4182.
Knowledge about how children die in pediatric hospitals is limited, and this hinders improvement in hospital-based end-of-life care. In this study, the authors conducted a retrospective chart review of all the patients who died in a children's hospital between July 2011 and June 2014, collecting demographic and diagnostic information, hospital length of stay, location of death, and PC consultation. A qualitative review of provider notes and resuscitation records was used to create five mutually exclusive modes of death, which were then assigned to each patient. Analysis included the calculation of descriptive statistics and multinomial logistic regression modeling. Results demonstrated that the authors identified 579 patients who were deceased: 61% were <1 year of age. The ICU was the most common location of death (NICU 29.7%; PICU 27.8%; cardiac ICU 16.6%). Among the five modes of death, the most common was the withdrawal of life-sustaining technology (40.2%), followed by nonescalation (25.6%), failed resuscitation (22.8%), code then withdrawal (6.0%), and death by neurologic criteria (5.3%). After adjustment, patients who received a PC consultation were less likely to experience a code death, although African American patients were more likely than white patients to experience a code death, mostly because of code events occurring in the first 24 hours of hospitalization. The authors conclude that most deaths in a children's hospital occur in ICUs after the withdrawal of life-sustaining technology, and that race and PC involvement may influence the manner of a child's death.
Pivodic L, Smets T, Van den Noortgate N, et al. Quality of dying and quality of end-of-life care of nursing home residents in six countries: An epidemiological study. Palliat Med 2018 [E-pub ahead of print]; https://doi.org/10.1177/0269216318800610.
Nursing homes are among the most common places of death in many countries. In this study, the authors attempted to determine the quality of dying and end-of-life care of nursing home residents in six European countries. The design of the study was an epidemiological survey in a proportionally stratified random sample of nursing homes. The authors identified all deaths of residents of the preceding three-month period. Main outcomes were quality of dying in the last week of life (measured using End-of-Life in Dementia Scales–Comfort Assessment while Dying [EOLD-CAD]); quality of end-of-life care in the last month of life (measured using Quality of Dying in Long-Term Care [QoD-LTC] scale). Higher scores indicate better quality. The setting of the study was 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Participants were staff (nurses or care assistants) most involved in each resident's care. Staff returned questionnaires regarding 1384 (81.6%) of 1696 deceased residents. Results demonstrated that the EOLD-CAD mean score ranged from 29.9 in Italy to 33.9 in England, whereas the QoD-LTC mean score ranged from 35.0 in Italy to 44.1 in England. A higher EOLD-CAD score was associated with country (p = 0.027), older age (p = 0.012), length of stay ≥1 year (p = 0.034), and higher functional status (p < 0.001), whereas a higher QoD-LTC score was associated with country (p < 0.001), older age (p < 0.001), length of stay ≥1 year (p < 0.001), higher functional status (p = 0.002), absence of dementia (p = 0.001), and death in nursing home (p = 0.033). The authors conclude that the quality of dying and quality of end-of-life care in nursing homes in the countries studied are not optimal, including countries with high levels of PC development in nursing homes such as Belgium, the Netherlands, and England.