American Journal of Hospice and Palliative Medicine current issue

Advanced Dementia and the End of Life

Enck, R. E. — Mon, 01 Feb 2010 15:55:57 PST

Music as Language

Ready, T. — Mon, 01 Feb 2010 15:55:57 PST

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.

Methylphenidate Side Effects in Advanced Cancer: A Retrospective Analysis

Lasheen, W., Walsh, D., Mahmoud, F., Davis, M. P., Rivera, N., Khoshknabi, D. S. — Mon, 01 Feb 2010 15:55:57 PST

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.

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

Valente, S., Saunders, J. — Mon, 01 Feb 2010 15:55:57 PST

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.

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

Mon, 01 Feb 2010 15:55:57 PST

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.

Medical Students' Views and Ideas About Palliative Care Communicatio Training

Wittenberg-Lyles, E. M., Goldsmith, J., Ragan, S. L., Sanchez-Reilly, S. — Mon, 01 Feb 2010 15:55:57 PST

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.

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

Mon, 01 Feb 2010 15:55:57 PST

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.

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., Sheikh Moeen ul Haq, — Mon, 01 Feb 2010 15:55:57 PST

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.

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

Surjya Prasad Upadhyay, , Shiv Pratap Rana, , Mishra, S., Bhatnagar, S. — Mon, 01 Feb 2010 15:55:57 PST

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. — Mon, 01 Feb 2010 15:55:57 PST

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.

e-Health in Pediatric Palliative Care

Knapp, C. — Mon, 01 Feb 2010 15:55:57 PST

e-Health has the potential to improve pediatric palliative care. e-Health initiatives use the Internet or health information technology to improve quality of care and have the potential to decrease costs by reducing medical errors, reducing duplication of services, improving access to diagnostic and laboratory results, and improving communication between providers and patients, and so on. The majority of e-health initiatives are for adults and only a limited amount of evidence exists in the literature on e-health interventions in palliative care that are focused on pediatrics. To explore what role e-health could play in pediatric palliative care programs, this article aims to describe the Internet use in general in the United States and in palliative care, describe the use of health information technology in general in the United States and in palliative care, and suggest areas in pediatric palliative care that might benefit from e-health interventions.

Cleveland Clinic Palliative Medicine Grand Rounds: Introductory Piece

Walsh, D. — Mon, 01 Feb 2010 15:55:57 PST

Symptom Assessment in Palliative Medicine: Complexities and Challenges

Kirkova, J., Walsh, D., Russel, M., Hauser, K., Lasheen, W. — Mon, 01 Feb 2010 15:55:57 PST

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.

The Blessing of Hospice

Kruschke, C. A., Lee Leon, D. — Mon, 01 Feb 2010 15:55:57 PST

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.

Unlocking the Closed Door: Arguments for Open Access Hospice

Furman, C. D., Doukas, D. J., Reichel, W. — Mon, 01 Feb 2010 15:55:57 PST

The traditional view of standard hospice (SH) care is that once begun, the doorway toward curative and other forms of nonpalliative treatment is irrevocably locked. We will argue that such a traditional view needs to be reassessed in light of new arguments and data regarding access to these avenues of treatment. We will argue that patients should be supported in their transition from SH to open access hospice (OAH). Open access hospice should be available to all patients because of ethical arguments, patient satisfaction arguments, and costs of care arguments. More randomized controlled research trials need to be performed to study the impact of OAH versus SH. This research should focus on patient satisfaction, cost, and survival.