American Journal of Hospice and Palliative Medicine RSS feed -- OnlineFirst Articles

50 Pointers for a New Hospice Social Worker

Lee, D. F. — Tue, 27 Oct 2009 17:05:35 PDT

Barriers to Hospice Use and Palliative Care Services Use by African American Adults

Yancu, C. N., Farmer, D. F., Leahman, D. — Tue, 27 Oct 2009 17:05:34 PDT

This study explored the reasons for low levels of hospice participation by African Americans. Methods: Data about attitudes toward dying and death, advanced directives, and barriers to using hospice services were collected from 314 adults attending 11 diversely populated churches in North Carolina. Results: Almost all participants indicated (91%) willingness to use hospice, particularly if the hospice team were diverse (77%). Most are without a living will (72%) or health care power of attorney (81%); approximately half (54%) have shared final care wishes. Discussion: Despite evidence of a willingness to use hospice, African Americans were unlikely to complete advanced directives or share final care wishes. However, many were more likely to use hospice if the care team were diverse suggesting the importance of culture.

Palliative Oncology: Thalidomide

Prommer, E. E. — Tue, 20 Oct 2009 12:41:12 PDT

After decades of disuse because of its teratogenic effects, thalidomide has had a resurgence of use as a promising therapeutic agent for multiple myeloma. Its mechanism of action involves activation of the immune system, antiangiogenic effects, and inhibition of cytokines. Thalidomide does not interact with the cytochrome oxidase system. It is not significantly metabolized, but it does undergo nonenzymatic hydrolysis in plasma. The resulting products are inactive. Despite the potential adverse effects of peripheral neuropathy, constipation, deep vein thrombosis, somnolence, rash, and orthostatic hypotension, thalidomide is an effective first-line agent for multiple myeloma in combination with dexamethasone or melphalan and prednisone. It has also been studied in the palliative care of patients with cytokine-based syndromes such as anorexia-cachexia syndrome. This review describes its use in oncology, hematology, and palliative care.

Hospice Disease Types Which Indicate a Greater Need for Bereavement Counseling

Jones, B. W. — Fri, 16 Oct 2009 15:40:17 PDT

This article attempts to find a correlation between certain disease types and increased needs for bereavement services for survivors. Data were examined from those requesting increased bereavement services from a hospice provider in Kentucky, over a 2-year span. The survivors were then matched with the disease type of their loved one to see whether there was a connection between the two. Although limited in its scope and focus, the study revealed that patients surviving Alzheimer disease, lung cancer, and renal failure consistently (at least 50% of the time) required increased bereavement services after the death of their loved one. Other disease types indicated more erratic patterns for increased grief services.

Predictors of Symptom Severity and Response in Patients With Metastatic Cancer

Fri, 16 Oct 2009 15:40:17 PDT

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

Deathbed Phenomena: Its Role in Peaceful Death and Terminal Restlessness

Mazzarino-Willett, A. — Thu, 08 Oct 2009 16:21:46 PDT

Dying patients and their caregivers frequently experience that which is known as deathbed phenomena, that is, visions of past deceased relatives or friends, religious figures, and a visionary language pertaining to travel. Collective research supports mounting evidence that deathbed visions typically yield peaceful deaths. Yet within the literature, numerous hospice patients experience the symptoms of terminal restlessness and frequently succumb to anguished deaths. Why are some patients and caregivers guided by peaceful deathbed phenomena and others are not? Does a relationship exist between the lack of deathbed phenomena and the onset of terminal restlessness in dying patients? This clinical paper intends to answer these questions and might elucidate the factors that contribute to a dying patient’s death ending as either a peaceful event or the one affected by terminal restlessness. This knowledge gained could lessen the occurrence of anguished deaths and perhaps change our way of viewing dying.

Medical Students' Views and Ideas About Palliative Care Communication Training

Wittenberg-Lyles, E., Goldsmith, J., Ragan, S. L., Sanchez-Reilly, S. — Thu, 08 Oct 2009 16:21:45 PDT

This study focused on the undergraduate medical student to identify views and ideas held toward palliative care communication training, pedagogical approaches to this training, and its perceived effectiveness and use in the medical field. Two focus groups consisting of fourth-year medical students were conducted, and their responses were analyzed using grounded theory categorization. Results indicated that students: (a) prefer to learn nonverbal communication techniques, (b) believe that natural ability and experience outweigh communication curriculum, (c) view the skill of breaking bad news as largely dependent on knowledge and expertise, and (d) prefer curriculum on palliative care and hospice to consist of information (eg, advance directives) rather than communication skills. Implications for these interpretive themes are discussed as well as future research and practice.

Documentation of Resuscitation Status in an Ambulatory Palliative Care Population: Results of a Prospective Observational Study From a Tertiary Cancer Care Centre in Pakistan

Hafeez, H., Anwar, N., Haq, S. M. u. — Thu, 08 Oct 2009 16:21:45 PDT

Background: It was observed in our hospital that a lot of patients with advanced progressive disease were being seen in the palliative care clinics without documentation of their resuscitation status. Aim: To assess the documentation of resuscitation in patients referred to palliative care clinic. Methods: Retrospective review of medical records of patients referred to the palliative care clinic was done looking for evidence of documentation of code status. Results: Only 77 of the 316 patients seen in clinic during this period had any documentation of code status. More than half of these had been referred by the internists who had documented the code status as well. Conclusions: As a result of the study, we have introduced changes aimed at ensuring better documentation of resuscitation status.

The Use of Transdermal Fentanyl in Cancer Pain : A Compliance Study of Outpatients in Taiwan

Fri, 02 Oct 2009 16:24:32 PDT

The aim of this study is to investigate cancer patients' response and side effects associated with transdermal therapeutic fentanyl (TTS-F), whose pain was hardly controlled by nonweak/weak opioids in Taiwan. From 2005 to 2006, 822 outpatients received TTS-F to collect pain assessment forms and diaries for 4 weeks. Most (78.7%) patients were initially prescribed 25 µg/h TTS-F. Doses were adjusted weekly at clinicians' discretion, according to pain assessment and side effects. Patients receiving 50 µg/h, 75 µg/h, and > 75 µg/h TTS-F had increased from 17.5% to 32.1%, 1.8% to 3.4%, and 1.9% to 2.2%, respectively, by week 2; further small increases were found in weeks 3 and 4. Pain palliation improved from 60.6% during week 1 to 78.6% at week 4. The common adverse effects were nausea/vomiting. Patient’s compliance was >90%. This study found that the TTS-F is effective and well tolerated.

Psychiatric Nurses' Expertise, Interest in End-of-Life Care, and Requests for Continuing Education on End of Life

Valente, S., Saunders, J. — Tue, 29 Sep 2009 15:31:19 PDT

Background: The time before dying can be extremely challenging and stressful. Gaps in end-of-life care include inadequate communication, education about end-of-life options, symptom control, and management of common mental illnesses (eg, mood disorders, dementia), and death anxiety. Psychiatric nurses are in a pivotal position to help address these gaps and improve end-of-life care. Psychiatric nurses can facilitate communication about end of life, educate patients about options, and provide consultation, assessment, and management of common psychosocial needs (eg, mood disorders, grief, and loss). Objective: This survey examined psychiatric nurses' perspectives of their skills, knowledge, expertise, continuing education needs, and recommendations for the role of the psychiatric nurse. Study design: Using a descriptive design, we surveyed a convenience sample of psychiatric nurses from the American Psychiatric Nurses Association. Results: Psychiatric nurses reported they were skilled in discussions of difficult topics, evaluation of mental status, and assessment and management of mood disorders, grief, and suicide risk. However, nurses asked for continuing education in focusing these skills for end of life, knowing the needs of the dying patient, and differentiating depression and dementia at end of life. Requests for continuing education on end-of-life care included issues about how to apply these psychiatric skills and knowledge to the dying patient and their families. Conclusions: Psychiatric nurses have skills and knowledge to reduce the gaps in end-of-life care. Many request continuing education to assist them to expand and focus their knowledge to use their psychosocial skills and to develop a specialty area in end-of-life care.

Noninvasive Ventilation in Immunosuppressed Patients

Namendys-Silva, S. A., Hernandez-Garay, M., Herrera-Gomez, A. — Wed, 23 Sep 2009 12:38:45 PDT

In immunosuppressed patients (ISP) with acute respiratory failure (ARF), invasive mechanical ventilation (IMV) is associated with high mortality rate. Noninvasive ventilation (NIV) is a type of mechanical ventilation that does not require an artificial airway. It has seen increasing use in critically ill patients to avoid endotracheal intubation. Acute respiratory failure due to pulmonary infections is an important cause of illness in ISP and their treatment. Immunosuppressive treatments have showed an increase not only in the survival but also in the susceptibility to infection. Several authors have underlined the worst prognosis for neutropenic patients with ARF requiring endotracheal intubation and IMV. The NIV seems to be an interesting alternative in ISP because of the lower risk of complications; it prevents endotracheal intubation and its associated complications with survival benefits in this population.

No Time for Death

Janvier, A. — Wed, 23 Sep 2009 12:38:45 PDT

Phase II Trial of Mirtazapine for Cancer-Related Cachexia and Anorexia

Riechelmann, R. P., Burman, D., Tannock, I. F., Rodin, G., Zimmermann, C. — Wed, 23 Sep 2009 12:38:44 PDT

We performed an open-label single-institution phase II trial of mirtazapine (15-30 mg by mouth [po] every day [qd]), a tetracyclic antidepressant that may lead to weight gain, for 8 weeks in nondepressed patients with cancer-related cachexia/anorexia (CRCA). The primary end point was the proportion of patients who gained ≥1 kg at week 4. Secondary end points were quality of life and appetite. From June 2006 to July 2007, 17 of 58 eligible patients were enrolled. On intention-to-treat analysis at week 4, 4 of 17 patients (24%) gained 1 kg or more, 1 patient maintained weight (gain of 400 g) and 2 patients lost weight (800 g and 1.2 kg); 24% and 6% improved appetite and health-related quality of life (HQOL), respectively. Mirtazapine is a promising agent for the treatment of CRCA.

A Comparative Study of 2 Sustained-Release Morphine Preparations for Pain in Advanced Cancer

Wed, 23 Sep 2009 12:38:45 PDT

Purpose: Several sustained-release morphine (SRM) formulations are available internationally. This study compared 2 such products available in the United States, SR1 and SR2. Patients and Methods: In an open-label study, patients with advanced cancer pain were randomized to receive SR1 or SR2 every 12 hours around-the-clock (ATC) for 5 days, with immediate release (IR) liquid morphine for rescue dosing (RD). Efficacy, safety, and patient acceptability were determined. Results: A total of 32 patients were evaluable for efficacy and toxicity. Pain scores, RD dosage, RD frequency over 5 days, RD within 3 hours before and after the scheduled SRM, and 8 of the 11 evaluated side effects were higher in the SR1 group. At presumed morphine steady state (day 3), pain scores (P = .05), RD dosage (P = .07), RD frequency (P = .07), and number of RD ±3 hours from scheduled SRM dose (P = .05) were consistently greater in the SR1 group (despite a higher median morphine dose in that group). There was a clinically important and directionally consistent trend that favored SR2, although not all were statistically significant. Patient preference favored SR2 (P < .05). Neither group had difficulty swallowing SR1 or SR2. Conclusions: This is the first study that directly compared two 12-hour SRM formulations. The data suggested, by multiple clinically important measures, that SR2 may provide superior analgesic efficacy and less toxicity compared to SR1. It also supports the concept that it cannot be assumed that different SR formulations of a given opioid are clinically equivalent. A larger study is needed to confirm our findings.

Religious Care Required for Japanese Terminally Ill Patients With Cancer From the Perspective of Bereaved Family Members

Tue, 15 Sep 2009 11:08:12 PDT

The aim of this study was to explore the most suitable religious care for Japanese terminally ill patients with cancer based on the opinions of bereaved family members. A multicenter questionnaire survey on palliative care service was sent to 592 bereaved family members of patients with cancer who were admitted to palliative care units in Japan, and 430 responded by mail. In the section of the questionnaire about religious care, 382 responses were used for quantitative analysis, and 71 responses about religious care for qualitative analysis. In the current study, the 71 responses were grouped into families with and without a religion and were analyzed qualitatively. Families with a religion (N = 28) chose answers such as "Instrumental care" such as music or a religious event, "Freedom of choice of kinds for religious care," "Staff involvement of religious care," "Meeting with a pastoral care workers," and "Burden of offering a different kind of personal religion." In contrast, families without a religion (N = 44) chose answers such as "Instrumental care," "Freedom of choice whether patients receive religious care or not," "Spiritual care," "Not being able to accept religious care," and "Burden of thinking about a religion and nuisance." These findings suggest that Japanese bereaved families with a religion generally regard religious care positively and prefer care through their own religion, whereas some families without a religion require religious care but some do not prefer it.

The Blessing of Hospice

Kruschke, C. A., Leon, D. L. — Tue, 15 Sep 2009 11:08:12 PDT

Hospice care is provided at the end of life. End-of-life care is not discussed until it is needed. The average person knows the term but not what it really means until a terminal diagnosis is made. This article discusses the end-of-life issues faced by our mother and how it affected the entire family. The hospice home our mother lived in during the last 2 weeks and 1 day of her life showcased the best hospice has to offer in terms of physical, emotional, and spiritual support.

Methylphenidate Side Effects in Advanced Cancer: A Retrospective Analysis

Lasheen, W., Walsh, D., Mahmoud, F., Davis, M. P., Rivera, N., Khoshknabi, D. S. — Thu, 10 Sep 2009 14:45:26 PDT

Introduction: Methylphenidate (MP) is often recommended for symptom control in advanced cancer. Little is known about its side effects in frail adults. Objectives: To evaluate MP-associated symptoms or side effects (S/E). Methods: Data was collected from 2 published prospective cohort series and a phase 2 study of MP for symptom control in advanced cancer. All 3 reports had identical dosing schedules and symptom assessments. Initial MP doses were 10 mg/d (5 mg at 8 am and at 12 noon) titrated up to a maximum of 30 mg/d. Depression, fatigue, and symptoms identified as possible MP S/E were evaluated for presence (prevalence) and for severity (using categorical scales) before MP (day 0) and on days 3, 5, and 7 thereafter. The categorical scale used was none, mild, moderate, and severe. Results: 62 patients were enrolled. Fifty completed 7 days of MP with a median age of 69 (range 30-90) years. Thirty-five received MP 10 mg/day. Most (96%) had improvement in depression and/or fatigue. Among the 62 patients, new symptom prevalence throughout the study was agitation (16%), insomnia (16%), dry mouth (15%), nausea (10%), tremors (6%), anorexia (5%), headache (3%), palpitations (2%), and vomiting (2%). Patients could have more than 1 symptom simultaneously. Seven (11%) withdrew due to MP S/E. Some symptoms present before MP showed significant improvement during MP therapy. Conclusions: (1) Treatment with MP (10-20 mg/d) in advanced cancer is well tolerated. (2) S/E symptoms with MP appeared to improve spontaneously despite continued MP therapy. (3) Depression and fatigue improved at doses lower than those recommended in other clinical conditions. (4) MP improved depression and fatigue, and some secondary symptoms associated with them. Methylphenidate (MP) appears safe when used in the treatment of depression and fatigue in advanced cancer.

Successful Treatment of an Intractable Postherpetic Neuralgia (PHN) Using Peripheral Nerve Field Stimulation (PNFS)

Upadhyay, S. P., Rana, S. P., Mishra, S., Bhatnagar, S. — Fri, 21 Aug 2009 16:37:42 PDT

Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome that arises as a sequel of herpes zoaster eruption. The treatment of postherpetic neuralgia is medically challenging and often frustrating in some situation as the exact mechanism of neuralgia is poorly understood and multiple and complex pathophysiology is postulated requiring poly pharmacy, which itself leads to many side effects. Here, we present a successful management of supra-orbital PHN using peripheral nerve field stimulation (PNFS), which was refractory to the commonly used pharmacological treatment. After successful trial stimulation, permanent stimulator was placed successfully, patient medication were tapered off within 2 weeks. At present, patient is in 8-week poststimulation with excellent pain relief, without any side effect.

Management of a Request for Physician-Assisted Suicide

Rodriguez Davila, S. L., Vidal, E., Stewart, J. T., Caserta, M. T. — Fri, 07 Aug 2009 15:51:00 PDT

With the legalization of physician-assisted suicide (PAS) in several states, it remains controversial whether present guidelines take into account the complexity of identifying treatable sources of suffering, including underlying depression and other psychiatric disorders, in this high risk population. We present a case in which a patient with end-stage prostate cancer requested PAS; this request was in a state where PAS is not a legal option. He was evaluated psychiatrically and was not found to be depressed, but ample opportunities were found to improve his quality of life. With appropriate treatment, he lost interest in PAS as an option. We discuss the need for a comprehensive evaluation to properly assess and manage the untreated physical and emotional suffering that may influence a patient’s decision to hasten death.

Symptom Assessment in Palliative Medicine: Complexities and Challenges

Kirkova, J., Walsh, D., Russel, M., Hauser, K., Lasheen, W. — Fri, 31 Jul 2009 17:04:28 PDT

Symptoms are important patient-reported outcomes (PRO), which help to evaluate the impact of diseases and treatments and assess quality of care. Thorough symptom assessment is a challenge, as patients in palliative settings are often polysymptomatic and easily fatigued. There is no consensus about standardization of symptom assessment in palliative medicine. The available research provides some methodological guidance, but the psychometric properties of structured multisymptom assessments are largely understudied. New approaches may improve the efficacy of clinical assessment and create instruments with greater clinical utility. In this article, we discuss current methodological concepts of symptom assessment in clinical practice, specifically with reference to symptom questionnaires appropriate for palliative medicine.

Music as Language

Ready, T. — Wed, 01 Jul 2009 15:05:54 PDT

This article is an inquiry into the potential role of music in helping to address and to articulate complex emotional states such as the feelings patients might experience during the process of an illness or while undergoing bereavement. The article is centered on the role music played in structuring and articulating the cancer treatment experience of my infant nephew. What is woven around that central core is a synthesis and analysis of various philosophical perspectives, autobiographical vignettes, and empirical research. The writer postulates that music has an essential, inherent capacity to scaffold and contain emotions. Music is also considered a means to help facilitate the expression of difficult emotions such as lamentation, longing, and fear of the unknown that are often otherwise isolating, ineffable, or unbearable for patients. A major point of inquiry in this article is whether music can serve as a nurturing love object, or as a transitional object, for a patient during times of intense distress. What is also woven throughout this article is a subexploration of various philosophical perspectives on the cultural meanings and metaphors of illness.