American Journal of Hospice and Palliative Medicine®

The use of alcohol and medications among Swedish widows was analyzed in relation to various background variables. In Total, 1053 widows (640 widows younger than 65 years and 413 widows older than 65 years) answered the questionnaire. Many reported increased fatigue and sleeping problems. Around one-third of the widows reported drinking alcohol for relief of grief and inadequate support. Association existed between grief and increased intake of sedatives and sleeping pills, and between grief and drinking for relief of grief, as well as increase in intake of sedatives. In widows older than 65 years, perception of bad health, negative outlook for the future, and insufficient support seemed to increase the risk of more sedatives and sleeping pills. Negative outlook for the future also tended to lead to a heightened risk for increased intake of alcohol. There seems to be remaining health problems a long time after bereavement, and counseling may be needed especially when drugs and alcohol are extensively used.

We studied the prevalence of specific barriers that prevent indigent homebound older adults from obtaining advance directives and tested the effectiveness of clinical reminders for lowering the number of clients without advance directives. Case managers interviewed 1569 clients to determine whether they had an advance directive. All 530 clients without advance directives were contacted 3 months later to determine if advance directives had been obtained. Clients who still did not have advance directives were asked to list 1 or more reasons they did not have advance directives. About 57.8% of the barriers identified may reflect reluctance on the part of clients to address their own mortality. Reminders by the case managers were ineffective at lowering the number of homebound older adults without advance directives. Further studies are needed to identify and design strategies for convincing this population of homebound elderly to establish advance directives.

Integrating end-of-life care training into the clinical years of medical school has been promoted to enhance education in this area. To assess the effectiveness of an end-of-life care exercise integrated into clinical clerkships, we compared the level of preparedness in end-of-life care reported by students who did or did not complete the exercise. A greater proportion of students who completed the exercise compared with those who did not felt prepared in end-of-life care [50.7% (39/77) vs 35.6% (64/180); P = .02]. Among 5 domains of skills examined, significant differences were seen in interviewing/communicating (3.7 vs 3.5; P = .05) and management of common symptoms (3.3 vs 3.0; P < .01). We conclude that a ward-based integrated end-of-life care exercise may improve graduating students' self-reported preparedness to care for patients at the end of life.

Family members of patients with advanced illness have many questions. Unfortunately, several barriers prevent caregivers from discussing their questions with the physicians caring for the patient. Although question prompt sheets can be helpful in overcoming barriers to communication, few have been developed for family caregivers. The goal of this study, therefore, was to develop and test the acceptability and feasibility of a short question prompt sheet designed to encourage discussions about end-of-life concerns in an outpatient palliative care clinic. Our results demonstrated that caregivers wanted to discuss a variety of questions, primarily questions about medications, symptoms, support services, and what to expect. All caregivers thought that the question prompt sheets was easy to understand and felt comfortable completing it in clinic and the majority reported that the question prompt sheets made it easier for them to ask questions.

In an earlier qualitative research study exploring the meaning of preloss music therapy to bereaved caregivers who participated in sessions through a home-based hospice program, various narrative accounts revealed the significance of music in music therapy sessions. In this study, the role of music in palliative care music therapy is examined and representatively summarized, followed by a review of strategies provided by this author to home hospice patients and their caregivers. The reported perceptions of the meaning of music to 7 bereaved caregivers are presented, including a review of themes and associated narrations that illustrated its significance. The caregivers described these aspects of music in sessions to have memorable and lasting effects as follows: ``music is a conduit,'' ``music gets inside us,'' ``live music makes a difference,'' and ``music is love.'' Findings support the benefits of preloss music therapy for bereaved caregivers.

An estimated 500 000 children annually cope with life-limiting conditions expected to lead to premature death, but little is known about their health care expenditures at the end of life. This information is crucial for health planners to propose pediatric palliative care programs. This study aims to estimate predicted health care expenditures for Medicaid-eligible infants and children across several health service categories. Across these categories, infants and children were predicted to spend about US$110 000 and US$62 000 at the end of life, respectively. About 5% of infants and 8% of children incurred hospice expenditures. Results from the multivariate models suggest that black, non-Hispanic children are less likely than white, non-Hispanic children to use hospice care. Baseline expenditure information from this study can be used to develop integrated pediatric palliative care models. Our findings also suggest that many more children could potentially benefit by using hospice care at the end of life.

A community sample of 100 adults was asked to imagine that they had been recently diagnosed with a life-threatening illness. After reading about the services provided by hospice palliative care volunteers, participants were asked whether they would choose to have a volunteer help them and to give a reason for their answer. Eighty-nine of the 100 participants indicated that they would use the help of a volunteer. The most commonly given reasons for utilizing a volunteer included for the general support they provide, help with practical things, and lack of family nearby; reasons given for declining the services of a volunteer included ``I'm a private person'' and ``I don't need any help.'' Sixty-five participants knew that such a volunteer program was available. Of the 35 participants who did not, 31 (89%) expected their family doctor to tell them about it. The implications of these findings for volunteer program coordinators are discussed.

The few palliative care programs available to date in Saudi Arabia are largely hospital-based. Subacute palliative care models have not been developed yet. This retrospective review was conducted to assess the patterns and outcomes of hospital-based palliative care unit admissions in the absence of subacute palliative care models. We reviewed 759 eligible palliative care unit admissions related to 629 cancer patients during a 4-year period. Of all admissions, 66% were hospitalized through the emergency room. The average hospital stay was 24 days. The majority (86%) of patients died in-hospital. These results suggest that end-of-life quality indicators are unlikely to improve depending on hospital-based palliative care models only. To improve palliative care services in Saudi Arabia, other subacute models may need to be considered.

Neuropathic pain is common in the palliative care population; unless adequately treated, the pain can lead to chronic anxiety, depression, and social impairment. Many treatments have been proposed for neuropathic pain; however, it remains underdiagnosed, under-treated, and often requires long-term therapy with risk of adverse effects. Memantine (Namenda), an N-Methyl, D-aspartate receptor inhibitor currently marketed for the treatment of dementia, has been proposed as a medication for the treatment of neuropathic pain for its mechanism, safety, lack of serious adverse effects, and relatively rapid onset of action. However, clinical trials have not been promising so far and its routine use in neuropathic pain is not currently recommended.

Pain management and palliation face a great challenge with inclusion of the palliation teams from the earliest phases of diagnosis. The presented case report highlights that early inclusion of pain and palliative physicians in patient care demands comprehensive evaluation of the symptoms by the palliative physicians with possibly curable comorbid conditions requiring active and aggressive curative management. In summary, it is crucial for the treating palliative physician to be more proactive in the management of comorbid treatable conditions in a patient who may be an established case of advanced stage cancer.