American Journal of Hospice and Palliative Medicine®

Pharmacists have much to offer in caring for patients with an advanced illness. To celebrate the role of pharmacists in palliative care, we wanted to share 50 excellent reasons to love your pharmacist. This list was compiled by 3 pharmacists specializing in end-of-life care spanning from inpatient palliative care to home-based hospice. Our goal is to increase awareness among other hospice and palliative care practitioners by recognizing the skills pharmacists contribute in caring for patients at the end of life. We divided the list into categories: provision of pharmaceuticals, optimizing medication regimens, education and drug information, patient safety, and administration/formulary management.

The aim of this survey was to assess the opioid use in the last week of life of cancer patients admitted at an acute palliative care unit. From a consecutive sample of patients surveyed for a period of one year, patients who died in the unit were selected. Type of opioid, route of administration, and doses were recorded one week before death (or at admission time if the interval admission-death was less than one week) (-7), and on the day of death (Tend). Seventy-seven patients died in the unit in the period taken into consideration (12.4%). Oral morphine equivalents were 170 mg/day and 262 mg/day at -7 and Tend, respectively. Patients were receiving transdermal drugs or intravenous morphine at Tend, with a trend in the use of intravenous morphine at Tend (p=0.07). Intravenous morphine was more frequently used in sedated patients at Tend (p=0.015).No differences in age, gender, opioid doses, and OEI were found among opioids used. In patients who were sedated doses of opioids were significantly increased (p=0.012). In the last week of life intravenous morphine is the preferred modality to deliver opioids in an acute palliative care unit. Doses increases prevalently observed in sedated patients were performed before starting sedation with the purpose to treat concomitant distressing symptoms, such as dyspnoea.

Aims: To examine the relationship between self-efficacy with depression and physical distressing symptoms in males and females with cancer. Methods: A total of 41 males and 49 females with cancer completed the General Perceived Self-Efficacy Scale (GSE), depression scale, from the Hospital Anxiety and Depression Scale (HAD-D), and the MD Anderson Symptom Inventory (MDASI). Results: Correlations were found between depression and self-efficacy in males (r = -.501, P = .001) and females (r = -.588, P < .0005). The multivariate regression analysis revealed that education and depression could influence self-efficacy in male population. Urogenital versus breast cancer as well as depression seemed to influence females’ self-efficacy. Conclusions: Patients who had higher self-efficacy had lower depressive symptoms. Men with depressive symptoms and women with breast cancer and depression are more likely to have low self-efficacy than patients with other cancer types.

This study evaluated reasons why palliative care patients were readmitted within 30 days of discharge. A secondary purpose was to determine whether length of stay (LOS) was different between readmission reasons. From July 2006 to June 2007, 156 palliative care readmissions were identified. Codes were assigned to each readmission and included compliance issues, discharge planning, disease process, new diagnosis, premature discharge, surgical complications, and other. Results demonstrated that disease progression (63%) and development of new co-morbidities (17%) were the primary readmission causes. No significant differences among readmission causes for LOS were identified. As the primary reason for readmission was the disease process, a closer look at the most common disease processes and the specific complications that resulted in a readmission would be helpful in planning patient care.

The death of a spouse is a complicated experience in a family. Understanding the circumstances of the loss is part of the family’s healing process. The current qualitative phenomenological study builds on the existing studies by focusing on the lived experience of parents as they transition to single parenthood. Six individuals participated in this study. Data analysis revealed 5 themes related to the change to single parenting after the loss of the spouse including the need to revision the parenting role and the role of support. The study has implications for the design of interventions and groups following the death of a spouse.

The value of interdisciplinary collaboration is a significant aspect of the palliative care philosophy, as identified by the founder of the modern hospice movement Cecily Saunders. The purpose of this descriptive study was to explore the experiences of hospice medical directors within this collaborative context. Open-ended interviews with 17 hospice medical directors were done and their responses were thematically analyzed. These narratives present a very positive collaborative experience by these medical directors in their hospice settings. Assisting medical directors to find time and financial opportunities for professional development and support within their role was found to be an opportunity to further improve collaboration.

Implantable cardioverter defibrillators (ICDs) and pacemakers may change the character of an individual’s eventual death. The objective of this study was to explore hospice and palliative care provider attitudes and experience in managing ICDs and pacemakers for patients near the end of life. A voluntary survey was distributed to session attendees at a national conference. Doctors and nurses surveyed overwhelmingly agreed it is appropriate to disable these devices in a terminally ill patient who does not wish to be resuscitated or prolong life. However, respondents emphasized a less defined burden for pacemakers. Respondents also reported limited involvement in such cases and few institutional protocols. As more terminal patients have these devices, research and education on device management protocols/guidelines and on provider communication skills are critical.

Objective: It has been estimated that 15% to 40% of chronic cancer pain has a neuropathic component, and this type of pain often responds poorly to opioids. In an attempt to provide increased pain relief for patients with intractable cancer pain, unconventional agents and interventional management approaches have received considerable attention. Spinal cord stimulation (SCS) has been used with increased frequency for the treatment of intractable cancer pain. Methods: The patients with a history of cancer-related chest wall pain underwent an uneventful SCS trial with percutaneous placement of 2 temporary 8-electrode leads (Medtronic Inc, Minneapolis, Minnesota) placed at the level of T3-T4-T5. Results: After experiencing excellent pain relief over the next 2 days, the patients were implanted with permanent leads and rechargeable generator 2 to 2 ½ weeks later and reported sustained pain relief at 12-month follow-up visit. Conclusion: SCS provides an effective, alternative treatment option for select patients with cancer-related chest wall pain who have failed conservative treatment. SCS may provide pain relief with advantages over conservative treatments and more invasive techniques.

Constipation is a common problem in palliative care. In spite of the most vigilant protocol, some cases can fly under the radar and present in atypical fashion. We report 2 cases of fecal retention, which presented as acute renal failure. Our goal is to bring attention to this problem and briefly discuss the challenges associated with managing this common problem.

Multiple, complex factors influence end-of-life (EOL) decisions for all persons. In the African American population, these factors include history of disparities and discrimination in health care, which may affect the individual and the family, family system beliefs, values, and practices, and health care system issues. Family dynamics have an especially important role in treatment decisions for loved ones with advanced disease. A family systems framework can guide the clinicians in appreciating care needs and preferences at EOL. Understanding why so many African Americans choose aggressive and often burdensome care, even at the expense of suffering, is important for communication about options at the EOL and the delivery of quality care at the EOL.

This article describes a symposium about the clinical challenges of providing care to persons with dementia and their families. The plenary session addressed the bereavement process in the general older adult population, neurocognitive processes that alter the grief process in persons with dementia, and therapeutic approaches to support grieving persons in different stages of dementia. Participants from diverse health care disciplines met in small groups to identify (1) current responses to persons with dementia and their families who experience a loss; (2) barriers to providing effective responses; and (3) possible interventions to improve care. Two general types of interventions emerged: practical/agency support and spiritual/affective engagement.