Abstract
Wiersma M, Ghinea N, Kerridge I, Lipworth W. “Treat them into the grave”: Cancer physicians' attitudes towards the use of high‐cost cancer medicines at the end of life. Sociology Health Illness 2018 [E-pub ahead of print]; DOI: 10.1111/1467-9566.12830.
The prescribing of high‐cost cancer medicines at the end of life has become a focus of criticism, due primarily to concerns about the safety, efficacy, and cost‐effectiveness of these medicines in this clinical context. In response to these concerns, several interventions have been proposed—frequently focused on improving physician–patient communication at the end of life. Underpinning these strategies is the assumption that the prescribing of high‐cost cancer medicines at the end of life is primarily the result of poor communication on the part of cancer physicians. In this article, the authors explore the factors perceived by cancer physicians to be driving the use of high‐cost cancer medicines at the end of life. Drawing on semistructured interviews with 16 Australian oncologists and hematologists, the authors demonstrate that these physicians believe that the use of high‐cost medicines at the end of life is driven by multiple factors—including individual, interpersonal, sociocultural, and public policy influences. The authors conclude that these factors, and their interactions, need to be taken into account in the development of public policy and clinical interventions to address the use of high‐cost medicines at the end of life.
Wand O, Guber E, Guber A, et al. Inhaled tranexamic acid for hemoptysis treatment: A randomized controlled trial. Chest 2018;154:1379–1384.
Tranexamic acid (TA) is an antifibrinolytic drug currently used systemically to control bleeding. To date, there have been no prospective studies of the effectiveness of inhaled TA for the treatment of hemoptysis. The goal of this study was to prospectively assess the effectiveness of TA inhalations (i.e., nebulized TA) for hemoptysis treatment. The study was a double-blind randomized controlled trial of treatment with nebulized TA (500 mg tid) versus placebo (normal saline) in patients admitted with hemoptysis of various etiologies. Patients with massive hemoptysis (expectorated blood >200 mL/24 hours) and hemodynamic or respiratory instability were excluded. Mortality and hemoptysis recurrence rate were assessed at 30 days and following 1 year. Results demonstrated that 47 patients were randomized to receive TA inhalations (n = 25) or normal saline (n = 22). TA was associated with a significantly reduced expectorated blood volume starting from day 2 of admission. Resolution of hemoptysis within 5 days of admission was observed in more TA-treated patients than in those receiving placebo (96% vs. 50%; p < 0.0005). Mean hospital length of stay was shorter for the TA group (5.7 ± 2.5 days vs. 7.8 ± 4.6 days; p = 0.046), with fewer patients requiring invasive procedures such as interventional bronchoscopy or angiographic embolization to control the bleeding (0% vs. 18.2%; p = 0.041). No side effects were noted in either group throughout the follow-up period. In addition, a reduced recurrence rate was noted at the one-year follow-up (p = 0.009). The authors conclude that TA inhalations can be used safely and effectively to control bleeding in patients with nonmassive hemoptysis.
Hogden A, Aoun SM, Silbert PL. Palliative care in neurology: Integrating a palliative approach to amyotrophic lateral sclerosis care. EMJ Neurol 2018;6:68–76.
This narrative review examines connections between neurology, specialist palliative care, and an integrated palliative approach to care for people living with neurodegenerative conditions. To illustrate the complexities of including palliative care in the management of neurodegenerative conditions, amyotrophic lateral sclerosis (ALS) is used as a case study. Challenges to coordinated ALS care and smooth care transitions between multiple services and health care professionals are discussed, including the timing of palliative care delivery in ALS, the education and training needs of health care professionals, and misperceptions of palliative care held by health care professionals, patients, and families. The benefits of adopting an integrated palliative approach to care for patients, families, and health care professionals are clarified. To enhance this, a family perspective is given on experiences of ALS neurology and palliative services, the challenges they faced, and aspects of care that facilitated the patient's preferences for the time they had left. This review concludes that a palliative approach integrated into the care plan of people with ALS from the time of diagnosis can optimize quality of life by relieving symptoms; providing emotional, psychological, and spiritual support prebereavement; minimizing barriers to a comfortable end of life; and supporting the family postbereavement. These outcomes can only be achieved if palliative care knowledge and expertise are extended beyond the domain of specialist palliative care services to include the full scope of health and community-based care. These challenges and potential actions are common for several neurodegenerative pathologies, and recommendations are made for enhancing the training of neurology health professionals within the wider community.
Cross LA. Compassion fatigue in palliative care nursing: A concept analysis. J Hospice Palliat Nurs 2019;21:21–28.
The purpose of this review was to define compassion fatigue in the context of palliative care nursing. Compassion fatigue was first introduced as a description for nursing burnout; however, it was not fully described. An initial concept analysis within nursing placed it in terms of a psychological model for secondary traumatic stress disorder, with continual revisions of this application. Palliative care nurses are routinely exposed to pain, trauma, and the suffering they witness by nature of ongoing symptom management and end-of-life care delivery; however, the focus of care is on healthy end-of-life management rather than preservation of life. The literature was reviewed to provide clarification of compassion fatigue for palliative care nurses to assist in future identification and direction in the profession. CINAHL, EBSCO, Journals@Ovid, MEDLINE, PsycINFO, PubMed, and ScienceDirect databases were queried for peer-reviewed literature, and dictionaries were examined for subject-specific definitions. The method that was used was a concept analysis in the tradition of Walker and Avant. A concept definition was proposed for the discipline of palliative care nursing. Identification of compassion fatigue for this profession helps facilitate the recognition of symptoms for a group that deals with patient suffering on a regular basis.
Perissinotto C, Holt-Lundstad J, Periyakoil VS, Covinsky K. A practical approach to assessing and mitigating loneliness and isolation in older adults. J Am Geriatr Soc 2019 [E-pub ahead of print]; DOI: 10.1111/jgs.15746.
Loneliness and social isolation are strongly associated with several adverse health outcomes in older persons, including death and functional impairments. The strength of these associations has been compared with smoking. Accordingly, loneliness and isolation have significant public health implications. Despite the adverse impacts of loneliness and social isolation on quality of life, and their strong association with health outcomes, the evaluation of loneliness and isolation has not been integrated into medical care. The risks for loneliness may be of particular concern to persons with serious illness as patients and caregivers cope with the experience of loss, loss of independence, and increasing care needs. To date, there has been no uniform way of evaluating and documenting loneliness and social isolation as a part of a review of a patient's social determinants of health. This article provides a framework for health care systems, providers, and community members working with older adults to (1) understand loneliness, isolation, and its counterpart social connection; (2) describe the different ways loneliness affects health; and (3) create a framework for asking about and documenting these experiences. Finally, because the lack of studies assessing whether targeting loneliness can improve health outcomes is a major gap, the authors provide guidance on the future of interventions.