American Journal of Hospice and Palliative Medicine recent issues

Empathy

Rousseau, P. — 2008-09-02

Determinants of Home Death in Palliative Home Care: Using the interRAI Palliative Care to Assess End-of-Life Care

Brink, P., Frise Smith, T. — 2008-09-02

Many terminally ill patients are given the choice to die at home. This study identified determinants of home death among patients receiving palliative home care. Health information was collected using the interRAI palliative care assessment tool. The sample included health information from 536 patients receiving home health care from one community care access centre in Ontario, Canada. Patients who died at home were more likely to be functionally impaired and less likely to live alone. The patients' wish to die at home and the family's ability to cope were strong determinants of home death. This study suggests that the presence of a supportive family that is able to work with the health care team to implement a plan of care is important to the patients' ability to die at home. This study highlights the need to treat the patient and the caregiver(s) as a unit of care.

Death-Talks: Transformative Learning for Physicians

Moon, P. J. — 2008-09-02

Conversations between physicians and their patients concerning terminal conditions are undoubtedly an uneasy process. These conversations are referred in this article as death-talks. Death-talks are social engagements among meaning-making human beings, and such encounters comprise complex grief dynamics as well as opportunities for personal insight. Towards preparing for and improving upon such sensitive and crucial talks, physicians must become growingly informed of their own existential standpoints in order to exude a more authentic presence. Transformative Learning is a theory of adult learning offering a rationale for physicians to exercise critically reflexive learning towards formulating a more meaningful medical and human care for those who are dying and their grieving relations.

Are Our Investments Paying Off?: A Study of Reading Level and Bereavement Materials

Rathbun, A., Thornton, L. A., Fox, J. E. — 2008-09-02

The purpose of this article is to discuss the findings of a study that examined bereavement materials for reading level. The main research question for the study was: are printed hospice bereavement materials written at an eighth grade level or below? Readability was determined for approximately 90 individual pieces of hospice bereavement literature. The literature came from materials that were collected in a larger study and included bereavement letters to families and other educational and resource materials available to the bereaved families, the caregivers, and the public. The method used to perform readability on the materials was the Simplified Measure of Gobbledygook. This process has been used to determine readability for more than 35 years and is widely accepted by the literacy community. Results of the study revealed that the materials analyzed were written at just above a 10th grade reading level.

Intravenous Morphine Can Avoid Distressing Constipation Associated With Oral Morphine: A Retrospective Analysis of Our Experience in 11 Patients in the Palliative Care In-Patient Unit

Mazumdar, A., Mishra, S., Bhatnagar, S., Gupta, D. — 2008-09-02

Morphine is the preferred strong opioid analgesic. Most of the adverse effects, such as daytime drowsiness, dizziness, mental clouding, and effects on cognitive and psychomotor function or nausea and vomiting, usually resolve with time. The main continuing adverse effect of morphine is constipation, and prophylactic use of laxative is almost always required. We are presenting retrospective data of 11 patients admitted in our palliative care unit over the past 5 months for new (not yet received any opioid analgesic in any form) and severe cancer pain management. It was found that none of the patients was having constipation with intravenous morphine. This finding can be explained on the basis of differences in pharmacologic profiles, in affinity to opioid receptor, and a higher exposure of opioid-binding receptor in the GI tract after oral administration of morphine compared with intravenous morphine. This explanation was further affirmed as constipation and need for laxative was reported by 7 of the 11 patients when they were given the equi-analgesic oral doses of morphine. Thus, the route of administration seems to be responsible for the above finding; hence, further evaluation with prospective observation and data collection is being planned to look for external validity in a larger population catered by our palliative care unit.

Racial/Ethnic Disparities in Liver Transplant Surgery and Hospice Use: Parallels, Differences, and Unanswered Questions

Smith, A. K., Ladner, D., McCarthy, E. P. — 2008-09-02

Despite well-documented racial/ethnic disparities in liver transplantation and hospice enrollment, reasons for these disparities are unclear. This study was conducted to elucidate what is known and unknown about the underlying causes of racial/ethnic disparities in liver transplantation and hospice enrollment. The root causes of inequities in access to liver transplantation and hospice are as yet poorly understood. Potential contributors to differences include differences in preferences, mistrust of the health care system, geographic factors such as neighborhood, health care system factors such as access to care and managed care versus fee-for-service insurance status, and social factors such as the availability of a full time caregiver. Although the goals of care are different, by examining hospice and transplant surgery side by side in the larger context of health disparities, a number of potentially promising avenues for future research have been uncovered.

No Relief in Sight: Postgraduate Training in Pain Management

Ogle, K. S., McElroy, L., Mavis, B. — 2008-09-02

This study investigated training in pain management in postgraduate medical education programs. A mail survey of program directors was conducted, evaluating the format of training in pain management and the self-assessed adequacy of the training. The response rate was 70%, with 188 total respondents. It included all programs in a large Midwestern state, representing most specialties. Just over half of all programs offered any formal training in pain management, and even fewer required it. Less than one quarter required a clinical component to such training. Nonetheless, an overwhelming majority of program directors (85%) rated their training as adequate or excellent. Improvements are clearly needed in postgraduate training in pain management, and external incentives, such as requirements in the accreditation process, will be needed.

Acupuncture Is Underutilized in Hospice and Palliative Medicine

Standish, L. J., Kozak, L., Congdon, S. — 2008-09-02

Acupuncture is a complementary and alternative medical modality. A considerable body of acupuncture research has accumulated since 1998. Acupuncture has been integrated into palliative care settings in the United Kingdom but is yet to be widely offered in the United States. The literature was searched to identify clinical trials involving acupuncture, palliative care, hospice, chronic obstructive pulmonary disease, bone marrow, and cancer. Twenty-seven randomized controlled clinical trials of acupuncture were found that reported on conditions common to the hospice and palliative care setting, including dyspnea, nausea and vomiting, pain, and xerostomia, and 23 reported statistically significant results favoring acupuncture use for the conditions investigated. Acupuncture is safe and clinically cost-effective for management of common symptoms in palliative care and hospice patients. Acupuncture has potential as adjunctive care in palliative and end-of-life care, and the evidence warrants its inclusion in reimbursed palliative and end-of-life care in the United States.

Provider Insights About Palliative Care Barriers and Facilitators: Results of a Rapid Ethnographic Assessment

Goepp, J. G., Meykler, S., Mooney, N. E., Lyon, C., Raso, R., Julliard, K. — 2008-09-02

Palliative care remains underutilized in the United States. This may represent failure of translation of research into practice (diffusion of innovation). Qualitative methods can identify barriers to and facilitators of diffusion of innovation. The aim is to identify potential barriers to and facilitators of inpatient palliative care utilization at a large urban hospital, as articulated by health professionals. Rapid ethnographic assessment methods were used among health professionals with subsequent extraction of predominant themes illuminating factors influencing adoption of palliative care services. In all, 3 stakeholder categories and 7 major themes emerged. Analysis revealed consistent need for organized, cross-disciplinary education/training services and a clearly-defined team approach. Denial at all stakeholder levels and in most themes was a barrier to implementation of palliative care. Consistent, defined educational, policymaking, and procedural standards were requirements for best adoption of palliative care. Denial was a striking obstruction to diffusion of innovation.

Shackled: The Challenge of Caring for an Incarcerated Patient

Courtwright, A., Raphael-Grimm, T., Collichio, F. — 2008-09-02

Hospice care for inmates is widely recognized as an important way of providing efficient, cost-effective palliative care to a growing number of dying inmates. The case presented here is of a 34-year-old inmate who was admitted to a tertiary-care hospital for diagnostic tests and treatment of non-small cell lung cancer. While he was in the hospital, his clinical status rapidly deteriorated and it was clear that palliative care was most appropriate. Prison restrictions prevented the health care team from sharing the patient's clinical status with his family. He was forbidden many interventions that would have improved his comfort, such as watching television. The problems illustrated by this case occur many times in United States tertiary-care hospitals, and it is hoped that by describing it, more compassionate care for inmate patients, regardless of location, can be provided.

Family Satisfaction Following the Death of a Loved One in an Inner City MICU

Kaufer, M., Murphy, P., Barker, K., Mosenthal, A. — 2008-09-02

This study examined family satisfaction with end-of-life care in a medical intensive care unit (MICU) before and after a palliative care intervention was implemented there. This intervention consisted of early communication, family meetings, and psychosocial support. Family members of patients who died in the MICU in 2005 and 2006 were contacted 2 to 16 months after the death of their relatives. Trained interviewers used the Family Satisfaction with Care Questionnaire to assess the families' perceptions of the care given to their family members. Minorities comprised 77% of the patient population. Comparison of the levels of family satisfaction in the preintervention and postintervention groups demonstrated that the intervention significantly improved the quality of end-of-life care, particularly through increases in family members' satisfaction with decision making, communication with physicians and nurses, and the death and dying process.

Give Me

Wyatt, T. — 2008-09-02

Beyond the Urns

Wyatt, T. — 2008-09-02

Nocturne

Wyatt, T. — 2008-09-02

Review Article: End-of-Life Care for Old People: A Review of the Literature

Agren Bolmsjo, I. — 2008-09-02

The aim of this study was to make an inventory of various aspects of end-of-life care of the old people. An additional aim was to illuminate gaps in existing knowledge. A systematic literature review focusing on intervention studies was carried out. Three concepts were of special interest: end-of-life care, palliative care, and terminal care. The result encompassed 29 studies, and the articles were grouped together under 4 headings: education and support for close relatives, education and support for staff, education and support for patients, and articles dealing with care planning. The result highlights the need for further research regarding end-of-life care in geographical and cultural settings that differ from those in the USA, needs of old people (ie, 80+), preferences concerning end-of-life care, and the effect of adjusted and generalizable palliative care models.

Destroying Myths

Moeen ul Haq, S., Butt, M., Ali, R., Bhattacharya, A. — 2008-09-02

Palliative care emergencies such as spinal cord compression require prompt diagnosis and treatment to get the best results. Hospitals dealing with these emergencies need to develop pathways of care for these patients based on best evidence derived from hard data. The authors looked at all spinal cord compressions that presented to their hospital over a 10-year period. The authors found that the commonest day of presentation of this condition was on Mondays and not Fridays as had been widely believed prior to this study. Hospitals are encouraged to look at hard data and not anecdotes when developing pathways of care for their patients.

Nurses' Perceptions of Hospice Palliative Care Volunteers

Claxton-Oldfield, S., Hastings, E., Claxton-Oldfield, J. — 2008-06-23

A total of 50 nurses (hospital and home care) responded to a survey designed to measure: (1) their attitudes toward, and knowledge of, hospice palliative care volunteers; (2) the types of tasks they felt it was appropriate for volunteers to perform; and (3) how valuable they felt different members of the hospice palliative care team are. In addition, they were asked to respond to some open-ended questions (eg, "Do you feel that it is appropriate for hospice palliative care volunteers to know patient medical information?"). The nurses' responses to the "Attitude/Knowledge" part of the survey revealed that they generally held positive attitudes toward volunteers. The majority of the nurses felt that it was appropriate for volunteers to perform most of the tasks listed, except for hands-on patient care. Nurses rated the value of nurses, family members, doctors, and pharmacists significantly higher than volunteers. Fifty-three percent of the nurses felt that volunteers should know patient medical information, and 77% thought that volunteers should have the opportunity to provide input regarding patient care. Also, 75% of the nurses felt that volunteers made their jobs easier, and 56% felt that volunteers should be included in team meetings. When asked to list the topics covered in a hospice palliative care volunteer training program, 73% of the nurses indicated that they were not sure or did not know what topics were covered, indicating a lack of knowledge regarding volunteer training.

Use of Advance Directives for Nursing Home Residents in the Emergency Department

Weinick, R. M., Wilcox, S. R., Park, E. R., Griffey, R. T., Weissman, J. S. — 2008-06-23

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.

Efficacy of a Scheduled IV Cocktail of Antiemetics for the Palliation of Nausea and Vomiting in a Hospice Population

Kumar, G., Hayes, K. A., Clark, R. — 2008-06-23

This is a retrospective analysis of 10 mg metoclopramide, 25 mg diphenhydramine, and 4 mg dexamethasone given intravenous piggyback every 6 hours for nausea or vomiting. Outcome measures were rapidity of symptom relief based on the self-report of the patient and nursing documentation of relief from symptoms of nausea or vomiting. Seven hundred and ninety seven patients were admitted to the inpatient hospice unit during a 2-year period. Sixty-three patients developed nausea or vomiting requiring the cocktail. Fifty-seven patients (90%) had objective response as reflected in nursing notes. Symptom relief was usually noted within 2 days with improvement in oral intake and enjoyment in activities, such as parties and family interactions. Partial relief was noted in patients with gastrointestinal malignancies and peritoneal carcinomatosis even with the addition of other antiemetics to the cocktail.

Residency Training in Advance Care Planning: Can It Be Done in the Outpatient Clinic?

Alderman, J. S., Nair, B., Fox, M. D. — 2008-06-23

Resident physicians are expected to assist their outpatients to understand and complete advance directives, but their efficacy in doing so remains uncertain. After receiving educational training, internal medicine residents identified at-risk patients and solicited them about advance directives. Residents completed pretest and posttest questionnaires that assessed their knowledge, skills, attitude, and comfort with advance directives. Patients were also surveyed about their attitudes regarding advance directives. Ten internal medicine residents and 88 patients participated. Residents' self-assessed knowledge rose from 6.0 to 9.2 on a 10-point Likert scale. Skills using advance directives increased from 4.0 to 7.9, attitudes improved from 6.0 to 8.4, and comfort rose from 5.4 to 8.9. Eighty-four percent of patients expressed interest in completing advance directives, and 16% actually completed documents. An educational intervention improved knowledge, skills, attitudes, and comfort with advance directives among internal medicine residents practicing in the outpatient setting. Meanwhile, patients demonstrated a strong interest in completing advance directives.

End-of-Life Experiences and the Dying Process in a Gloucestershire Nursing Home as Reported by Nurses and Care Assistants

Brayne, S., Lovelace, H., Fenwick, P. — 2008-06-23

This article presents an interim study into the end-of-life experiences of elderly residents in a Gloucestershire nursing home as reported by nurses and care assistants. It draws comparisons between the experiences of an end-of-life experiences pilot study conducted with the Camden Palliative Care Team in the United Kingdom with those of the nursing home staff to consider whether the dying experience of elderly nursing home residents is the same as those whose lives are foreshortened through terminal illness. It draws the conclusion that elderly residents have end-of-life experiences similar to those described in the Camden pilot study. It also examines the effect that end-of-life experiences have on the carers and reflects on possible needs for specialized training and support to deal with such existential issues.

Using the LCP: Bereaved Relatives' Assessments of Communication and Bereavement

2008-06-23

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. The authors studied whether use of the LCP affects relatives' retrospective evaluation of communication and their level of bereavement. An intervention study was conducted. During the baseline period, usual care was provided to dying patients. During the intervention period, the LCP was used for 79% of the patients. In total, bereaved relatives filled in a questionnaire for 57% of the patients, on average 4 months after death. In the intervention period, relatives had lower bereavement levels when compared with relatives in the baseline period (P = .01). Communication was evaluated similarly for both periods. We conclude that LCP use during the dying phase seems to moderately contribute to lower levels of bereavement in relatives.

Resolving End-of-Life Ethical Concerns: Important Palliative Care Practice Development Issues for Acute Medicine in Australia

McGrath, P., Henderson, D. — 2008-06-23

Historically palliative care research has focused on issues associated within the hospice and palliative care system. The findings presented in this manuscript reverse this assumption to argue that significant palliative care issues can only be understood if the focus is on the acute care system. Although a major proportion of deaths happen in the acute hospital setting, the acute care clinicians are the gate keepers to the palliative system. In short, understanding the ethical decision making of acute care professionals in relation to end-of-life care can illuminate many important palliative care practice development issues. The findings indicate that all professional groups in this study of an acute medical ward find end-of-life issues the most challenging of all the ethical challenges.

The Japan HOspice and Palliative Care Evaluation Study (J-HOPE Study): Study Design and Characteristics of Participating Institutions

Miyashita, M., Morita, T., Tsuneto, S., Sato, K., Shima, Y. — 2008-06-23

This article describes the study design and background data of participating institutions in the Japan HOspice and Palliative care Evaluation (J-HOPE) study. The J-HOPE study is a large nationwide survey about the dying experience of cancer patients. The primary aim of this article is to describe the design of the J-HOPE study for the bereaved family members of Japanese inpatient palliative care units and home hospices. Secondly, the aim was to describe characteristics of participating institutions. The authors conducted a cross-sectional questionnaire survey in 2007. One hundred Japanese inpatient palliative care units and 14 home hospices participated. The questionnaires were sent to 7955 bereaved family members of the Japanese inpatient palliative care units and 447 of the home hospices. The authors describe the structure of the Japanese inpatient palliative care units and home hospices, including type of staff, architectural structure, number of patients, and death. In addition, the authors describe available treatments at the Japanese inpatient palliative care units and home hospices.

End-of-Life Review

Aylor, A. L., Grimes, G. C. — 2008-06-23

Context: The term "End-of-Life Review" is often used by hospice workers in the context of spiritual apparitions or visitations prior to a patient's death. A review of the literature reveals no clear definition or categorization of this expression.

Objective: The aim of this study is to define the term "End-of-Life Review". Design: The study was performed using the Delphi method.

Setting/participants: A panel of interested parties was recruited from October 2006 to January 2007.

Intervention: Respondents were first asked to list their most common experiences associated with the term "End-of-Life Review," and then to rate each item as to how well it represented their understanding of this term. This process continued until subsequent rounds produce little change in the ranking of each item, suggesting a consensus. Conclusions: The term "End-of-Life Review" is a constellation of behaviors ranging from visitations from the departed to spiritual apparitions prior to death.

Management of Pericatheter Cerebrospinal Fluid Leak After Intrathecal Implantation of a Drug Delivery System

Singh, P. K., Jain, R., Mishra, S., Kumar, S., Bhatnagar, S., Deo, S. — 2008-06-23

Persistent cerebrospinal fluid leak is a known complication of intrathecal pump system insertion for drug delivery. Various treatment modalities, such as an epidural blood patch, use of glue, removal of catheter, and surgical closure of dura and subdural blood patch, have been reported previously. This report presents a 35-year-old woman in whom an intrathecal pump system was inserted for cancer pain management with intrathecal morphine. This was complicated by a persistent cerebrospinal fluid leak that was successfully managed by purse-string sutures over the dura around the catheter, without removing the intrathecal implant. The cause of the cerebrospinal fluid leak and different treatment approaches are discussed.

The Hospital-Survival and Prognostic Factors of Patients With Solid Tumors Admitted to an ICU

Mendoza, V., Lee, A., Marik, P. E. — 2008-06-23

The decision to admit a patient with cancer to the intensive care unit (ICU) is complex. There are limited data as to the outcome and prognostic factors of patients with solid tumors admitted to the ICU. A retrospective chart review was undertaken to evaluate this issue. Over an 18-month period, 147 patients with solid tumors were admitted to our ICU. Lung, colorectal, and breast were the commonest sites of the primary tumors, with 52% of patients having metastatic disease. A total of 79 (54%) patients survived to hospital discharge, with 50 (34%) patients being discharged to home. Metastatic disease and the requirement for vasopressor agents were independent predictors of poor outcome. The relatively high survival rate of this cohort of patients should prompt a reevaluation of the ICU admission criteria for patients with solid tumors who become critically ill.

Yet

Rousseau, P. — 2008-06-23

Review Article: Access to End-Of-Life Care Venues

Hallenbeck, J. — 2008-06-23

Quality of care at the end of life is strongly correlated with where patients die. This review discusses the influence of patient and health system variables affecting access to common venues of death-the acute care hospital, the nursing home, and home-with or without hospice. Access to care is considered in terms of a flow model, wherein pressure gradients push patients toward care in certain venues and away from alternatives. Dynamic interactions between patient-specific variables and health care system variables influence the nature of patient flow, moving patients toward certain terminal venues of care and away from others. Efforts to improve quality of care at the end of life must be cognizant of these effects and should work to adjust patterns of flow in more favorable directions.

Doreen and the Droopy Shoulder Syndrome

Clein, L. J. — 2008-06-23

Walking Habits in Elderly Widows

Grimby, A., Johansson, A. K., Sundh, V., Grimby, G. — 2008-04-29

Walking habits were studied in 3 groups of elderly widows. The average walking time per week was calculated from interviews or questionnaires. There was in a small studied group a tendency for walking time to be lower at 3 and 12 months after loss than at 4 or 5 years. An increased odds ratio was demonstrated in larger groups of widows for walking less than 120 minutes per week in those who "did not feel healthy," or who had "musculoskeletal health problems," or "cardiovascular health problems." Widows from a population-based study also showed increased odds ratio for not walking as long with "lack of friends" and "not being active in associations." This was not found in married women from the population study. Our results indicate that newly bereaved women may reduce their physical activity, and that the change in exercise habits may be associated with reduced perception of being healthy and a decreased social network.

"What Bothers You the Most?" Initial Responses From Patients Receiving Palliative Care Consultation

Shah, M., Quill, T., Norton, S., Sada, Y., Buckley, M., Fridd, C. — 2008-04-29

The purpose of this investigation is to describe how hospitalized palliative care patients respond to the question "What bothers you the most?" at the time of initial consultation. A retrospective descriptive content analysis of first person responses routinely recorded during initial interview (n = 286) was carried out. Responses were grouped in 7 major categories: physical distress (44%); emotional, spiritual, existential, or nonspecific distress (16%); relationships (15%); concerns about the dying process and death (15%); loss of function and normalcy (12%); distress about location (11%); and distress with medical providers or treatment (9%). Fifteen percent of responses were unable to be reliably categorized. Although many of our patients were not able to answer open-ended questions because of illness, those who did shared a wide range of concerns that provided a starting point for clinical prioritization. Further research into the use of such simple questions at time of initial consultation is warranted.

Lullament: Lullaby and Lament Therapeutic Qualities Actualized Through Music Therapy

O'Callaghan, C. — 2008-04-29

Lullabies and laments promote new awareness, enculturation, adaptation, and grief expression. These concepts' relevance to palliative care, however, has not been examined. In this study, a music therapist used a grounded theory—informed design to reflexively analyze lullaby and lament qualities, evident in more than 20 years of personal palliative care practice. Thus, the construct "lullament" emerged, which signified helpful moments when patients' and families' personal and sociohistorical relationship with lullabies and laments were actualized. Specific music could be both a lullaby and a lament. A music therapist can enable the lullament through providing opportunities for music-contextualized "restorative resounding," expressed psychobiologically, verbally, musically, and metaphorically.

Pediatric Palliative Care: An Assessment of Physicians' Confidence in Skills, Desire for Training, and Willingness to Refer for End-of-Life Care

Sheetz, M. J., Bowman, M.-A. S. — 2008-04-29

This study determines the confidence levels of physicians in providing components of pediatric palliative care and identifies their willingness to obtain training and to make palliative care referrals. Surveys were mailed to all physicians at Primary Children's Medical Center. The survey instrument includes 3 demographic items, 9 items designed to assess physician confidence in core palliative care skills, and 4 items designed to assess what steps physicians would be likely to take to assure that patients receive palliative care. Physicians were asked to rate their confidence levels to provide palliative care components on a 4-point scale for each of the items. Five hundred ninety-seven surveys were mailed, with 323 usable surveys returned. The proportion of physicians who rate their ability to provide palliative care as "confident" or "very confident" ranges from 74% for giving difficult news to families to 23% for managing end-of-life symptoms. Thirty-six percent of the physicians say they would be "likely" or "very likely" to attend training to improve their ability to provide palliative care to children. Eighty-six percent would be "likely" or "very likely" to refer for a palliative care consult and 91% to a home health agency or hospice. There is wide variation in the confidence levels of physicians to provide the core components of palliative care. Few are interested in obtaining additional training, but most are willing to obtain consultation or to refer to a palliative care service. These results argue in favor of hospital-based palliative care teams and for specialty training and certification in pediatric palliative care.

Needs of Elderly Patients in Palliative Care

Wijk, H., Grimby, A. — 2008-04-29

A pilot study on elderly patients' end-of-life needs was performed at a Swedish geriatric palliative ward. Thirty patients (15 men and 15 women; mean age, 79 years) with a primary diagnosis of cancer and admitted for palliative care were interviewed by a nurse using semistructured interviews. The study included demographic data, physical and psychologic status, and naming and ranking of individual needs. Elimination of physical pain was ranked as the primary need of half of the patients. Only when pain was eliminated or absent did other important needs (psychological, social, spiritual) appear frequently.

To Die, to Sleep: US Physicians' Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support

Curlin, F. A., Nwodim, C., Vance, J. L., Chin, M. H., Lantos, J. D. — 2008-04-29

This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians' religious characteristics, ethnicity, and experience caring for dying patients.

Some Common Problems Faced by Hospice Palliative Care Volunteers

Claxton-Oldfield, S., Claxton-Oldfield, J. — 2008-04-29

This paper examines 4 common problems that many hospice palliative care volunteers in Canada (and the United States) encounter, namely, being underutilized, being placed with a patient too late in the patient's illness, feeling undervalued by some members of the medical staff, and not being able to do more to help patients and their families. The implications of each of these problems are discussed along with suggestions for overcoming them. Finally, some ideas for future research are proposed.

Use of Thromboprophylaxis in Palliative Care Patients: A Survey Among Experts in Palliative Care, Oncology, Intensive Care, and Anticoagulation

Kierner, K. A., Gartner, V., Schwarz, M., Watzke, H. H. — 2008-04-29

Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovsky's index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovsky's index of 20 and by 85% when Karnovsky's index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

End-of-Life Care in Hancock County, Maine: A Community Snapshot

Ostertag, S. G., Forman, W. B. — 2008-04-29

This study presents a model for identifying end-of-life concerns in 1 rural community: Hancock County, Maine. Focus groups and structured interviews were held with primary care physicians, hospice staffs, clergy, hospice board members, long-term care facility staffs, and families of patients who had died either with or without hospice services. A list of suggestions for action within the community was generated from the interviews. Specific ideas targeted for implementation as a result of this project were educational sessions for long-term care facility staff, hospital grand rounds for primary care physicians, collaboration to bring information to the general public, stronger liaisons between long-term care facility and hospice staffs, and investigation of the development of a dedicated hospice facility. This is a simple, easily accomplished model to evaluate hospice needs in a small community.

Prediction of Patient Survival by Healthcare Professionals in a Specialist Palliative Care Inpatient Unit: A Prospective Study

Twomey, F., O'Leary, N., O'Brien, T. — 2008-04-29

Accurate prognostication is an enormous challenge for professionals caring for patients with advanced disease. Few studies have compared the prognostic accuracy of different professional groups within a hospice setting. The aim of this study was to compare the ability of 5 professional groups to estimate the survival of patients admitted to a specialist palliative care unit. No group accurately predicted the length of patient survival more than 50% of the time. Nursing and junior medical staff were most accurate while care assistants were least accurate. When in error, senior clinical staff tended to under-estimate survival. Independent mobility on admission was the only variable predictive of length of survival. Thus, professional groups differ in their prognostic accuracy. An awareness of a group's propensity to over- or under-estimate prognosis should be incorporated into future work on prognostication models.

Methadone

Chhabra, S., Bull, J. — 2008-04-29

Methadone hydrochloride is an old drug that has been in vogue off and on. It has complex pharmacodynamics and can be potentially fatal in inexperienced settings. Drug switching from an opioid to methadone or vice versa requires knowledge of equianalgesic dosing. It is critical when using the drug to monitor for signs and symptoms of toxicity so that overdosing or toxicity can be identified in a timely manner. This review discusses these important topics so that methadone can be used safely and effectively.

Locked-In Syndrome

Maurer, B. T. — 2008-04-29

Why Opioids and Sedatives May Prolong Life Rather Than Hasten Death After Ventilator Withdrawal in Critically Ill Patients

Bakker, J., Jansen, T. C., Lima, A., Kompanje, E. J. O. — 2008-04-29

The process of death in patients in whom cardiorespiratory support is withdrawn is related to the occurrence of tissue hypoxia that results from an imbalance between the demand for oxygen and the delivery of oxygen to the organs. Limiting the demand for oxygen may thus delay the occurrence of tissue hypoxia. Because the demand for oxygen increases significantly after ventilator withdrawal and because sedatives and opioids are known to decrease the demand for oxygen in patients with cardiorespiratory distress, these agents might thus actually prolong life rather than hasten death.

Palliative Care in Overdrive: Patients in Danger

Craig, G. — 2008-04-29

A Poor Prognosis: Guide or Misleading?

Wijnia, J. W., Corstiaensen, I. J. P. M. — 2008-02-21

Patients admitted to a palliative care unit have a limited life expectancy. Sometimes, however, the accuracy of the prognosis is compromised by atypical progress of a disease or incorrect assumptions. If a predicted short life expectancy proves to be longer, the increased need of care may result in chronic admission and in a significantly reduced quality of life. A given poor prognosis may be mistakenly adhered to and might lead to insufficient diagnostic procedures or treatment. However, palliative care requires a patient-oriented and active approach. To be aware of possible incomplete diagnostics is an important step in preventing adverse consequences of a wrong prognosis.

Characterizing Hospice Discharge Patterns in a Nationally Representative Sample of the Elderly, 1993-2000

Taylor, D. H., Steinhauser, K., Tulsky, J. A., Rattliff, J., Van Houtven, C. H. — 2008-02-21

The aim of this study is to identify the prevalence and correlates of individuals discharged alive from hospice in the Medicare program to determine whether the current hospice benefit matches the needs of dying patients. Using a nationally representative sample of age-eligible Medicare beneficiaries who died from 1993 to 2000, the use of hospice and other Medicare-financed care was analyzed during the last year of life for different groups of hospice users. It was found that 84.5% (n = 1029) of hospice users initiate and use it continuously until death; 15.5% of hospice users are discharged alive, with some later reinitiating hospice. The main difference between continuous hospice users and those discharged alive is the time survived after initial hospice use (those discharged alive live longer). After controlling for survival time, costs per day survived are similar for all groups. This study suggests several motivations for being discharged alive that are worthy of more research.

Narrative Accounts of Volunteers in Palliative Care Settings

Guirguis-Younger, M., Grafanaki, S. — 2008-02-21

The long and evolving tradition of palliative care has always had a strong volunteer dimension. The difficult nature of palliative care invites questions around why volunteers choose this particular line of contribution. To expand our knowledge of the elements that create meaning and capture the essence of volunteer experience, we asked volunteers to share the rewards and the challenges of their work and its personal meaning. Significant themes emerged around what volunteers considered the most valuable aspects of their experience. Volunteers identified freedom of choice and the ability to use their natural gifts as an important condition for satisfaction. In addition, they perceived emotional resilience and personal hardiness as important dimensions of their suitability for working in palliative care. Finally, volunteers felt that their approach must be one of a balanced perspective, with an understanding of life and death as part of the human condition.

A Day in the Life: A Case Series of Acute Care Palliative Medicine--The Cleveland Model

Lagman, R., Walsh, D., Heintz, J., LeGrand, S. B., Davis, M. P. — 2008-02-21

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.

Identification of Quality Indicators of End-of-Life Cancer Care From Medical Chart Review Using a Modified Delphi Method in Japan

Miyashita, M., Nakamura, A., Morita, T., Bito, S. — 2008-02-21

End-of life care is one of the principle components of cancer care. Measurement of the quality of care provided for end-of-life cancer patients is an important issue. The aim of this study was to identify the quality indicators (QIs) for end-of-life cancer care for Japanese patients using a medical chart review. A modified Delphi method for the development of QIs was adopted. Seventeen multi-professional specialists participated by rating the appropriateness and feasibility of potential QIs. Thirty QIs for end-of-life cancer care were ultimately identified within 4 domains: (1) symptom control, (2) decision-making and preference of care, (3) family care, and (4) psychosocial and spiritual concerns. These QIs will be useful for monitoring and evaluating end-of-life care for Japanese cancer patients. The QIs are feasible for use in any clinical setting and cover a comprehensive area in accordance with the World Health Organization's (WHO) definition of palliative care including physical, psychosocial, and spiritual concerns.

Confronting Death: Perceptions of a Good Death in Adults With Lung Cancer

Hughes, T., Schumacher, M., Jacobs-Lawson, J. M., Arnold, S. — 2008-02-21

Investigations regarding patients' concerns about death have focused on the importance of autonomy, resolution of concerns, family relationships, and religiosity, and relied on data from physicians, nurses, family members, and healthy older adults. Few studies have focused on patients with diseases that have short-term survival rates. This study examined lung cancer patients' perceptions of a good death. One hundred lung cancer patients answered open-ended questions about what a good death was and completed measures assessing coping, spirituality, religious coping, and life satisfaction. Content analysis revealed 4 themes describing a good death: (a) during sleep, (b) pain-free, (c) peaceful, and (d) quick. These findings have implications for those caring for terminally ill patients as the 4 themes differ from those derived from studies of more heterogeneous patients, their families, and health care providers.

Documentation in Palliative Care: Nursing Documentation in a Palliative Care Unit--A Pilot Study

Gunhardsson, I., Svensson, A., Bertero, C. — 2008-02-21

Palliative care seeks to enhance quality of life in the face of death by addressing the physical, psychological, social, and spiritual needs of patients with advanced disease. The purpose of this paper is to explore whether palliative patients' needs, nursing actions, and evaluation can be identified in the nursing documentation. Data consisted of reviews of patients' case records in a palliative care unit. Data were analyzed using content analysis and counting frequency of keywords used from the Well-being Integrity Prevention and Safety (VIPS) model, followed by an inductive analysis of the case record documentation aiming to identify palliative care components. The result shows that the documentation revealed physical care, especially pain, more frequently than other needs. Nursing documentation focuses on identification more than on nursing actions and evaluation.

Gabapentin for Intractable Hiccups in Palliative Care

Tegeler, M. L., Baumrucker, S. J. — 2008-02-21

Intractable hiccups are not common in the general population or in the palliative care population but can adversely impact quality of life and cause other complications such as weight loss and sleep disturbance. Many treatments have been proposed for intractable hiccups, but there is little consensus regarding treatment in the medical literature. This is partly because hiccups are relatively uncommon and many of the proposed treatments are unproven or have long-term side effects. Pharmacologic treatments rather than home remedies or surgical treatments are more appropriate for the palliative care patient. Gabapentin is a promising medication for the treatment of intractable hiccups for its safety, lack of serious side effects, and rapid onset of action. Further research is indicated to determine whether gabapentin is consistently effective.

A Movement of Archetypes

Ross, D. — 2008-02-21

The Ethical Concept of "Best Interest"

2008-02-21

A UK Perspective on Worldwide Inadequacies in Palliative Care Training: A Short Postgraduate Course Is Proposed

Charlton, R., Currie, A. — 2008-02-21

A chronological literature review illustrates how undergraduate and postgraduate education and training in the care of the dying and bereaved is inadequate worldwide. This is despite the foundation of the modern hospice movement in the United Kingdom in 1967 and its wider dissemination as a specialty in 1985. This situation has implications for those doctors working in both primary and secondary care, and this paper describes a 3-day course which has been successfully run in the West Midlands, UK, since 1997 for family physicians in training. A pre-course survey of 250, with a response rate of 54%, in 2003 revealed that 100% of respondents felt that they needed further training, and 51.5% said that they had had no previous training in palliative care.

Not "Just the Daughter"

Getter, A. — 2008-02-21

Letter to the Editor on: The Impact of Volunteering in Hospice Palliative Care

Marchese, K. A. — 2008-02-21