American Journal of Hospice and Palliative Medicine recent issues

Hospice--Palliative Medicine: A Look Back and Into the Future

Enck, R. E. — Wed, 18 Nov 2009 17:18:50 PST

Making Explicit the Contention in Hospice Care

Moon, P. J. — Wed, 18 Nov 2009 17:18:50 PST

At the core of hospice remains the defining nature of mortals tending to other mortals facing diagnosed terminality. Such situations are pregnant with meanings. As mortals are subjective beings, social engagements become inundated with meaning differences. This alludes to the inescapable occurrence of collisions and conflicts in meaning. It would behoove us to make explicit the contention that exists in hospice care, given that death is the nonnegotiable outcome to be diversely faced by all involved persons whose lived approaches related to death issues may characteristically lack unanimity. Toward elucidating the inherently contentious nature of hospice care, the dynamical influence of external forces that overlie thanatological matters in society and the complex human dynamic in hospice care situations are discussed. Practice suggestions for hospice staff are offered.

How to Attract More Males to Community-Based Hospice Palliative Care Volunteer Programs

Claxton-Oldfield, S., Guigne, S., Claxton-Oldfield, J. — Wed, 18 Nov 2009 17:18:50 PST

Two separate studies were conducted to better understand why so few middle-aged and older men volunteer in hospice palliative care; only about 10% of the patient/family care volunteers in New Brunswick’s community-based hospice palliative care volunteer programs are men. In study 1, 15 (22%) of the 68 men who read a brief description about the kinds of things that hospice palliative care volunteers do expressed an interest in this type of volunteerism. The main reasons given for their lack of interest included ‘‘being too busy’’ and ‘‘not being able to handle it emotionally.’’ At least one third of the men who said ‘‘No’’ to becoming a hospice palliative care volunteer expressed an interest in 10 of 13 other common volunteer activities (eg, driving). In study 2, 59 men were presented with a list of 25 tasks that hospice palliative care volunteers might perform when providing emotional, social, practical, and administrative support. The men were asked to indicate which tasks they would be willing to perform if they were a hospice palliative care volunteer. The men were least willing to serve on the board of directors (28%), provide hands on patient care (38%), and work in the volunteer program’s office (42%); they were most willing to talk to the patient (97%), share hobbies and interests with the patient (92%), listen to the patient’s memories and life stories (90%), and provide friendship and companionship (88%). The results of these studies may have implications for the recruitment of male volunteers to work with dying patients and their families.

Music Therapy in an Integrated Pediatric Palliative Care Program

Knapp, C., Madden, V., Wang, H., Curtis, C., Sloyer, P., Shenkman, E. — Wed, 18 Nov 2009 17:18:50 PST

National experts have recommended that children with life-limiting illnesses receive integrated palliative and medical care. These programs offer a variety of services, including music therapy. Using survey data from parents whose were enrolled in Florida’s Partners in Care: Together for Kids (PIC:TFK) program, this study investigates parents’ experiences with music therapy. About 44% of children with life-limiting illnesses and 17% of their siblings used music therapy. For children who used music therapy, multivariate results suggest that their parents were 23 times as likely to report satisfaction with the overall PIC:TFK program (P < .05) versus parents whose children did not use music therapy. Pediatric palliative care programs should include music therapy, although recruiting licensed music therapists may be challenging.

Advance Care Planning in the Primary Care Setting: A Comparison of Attending Staff and Resident Barriers

Tung, E. E., North, F. — Wed, 18 Nov 2009 17:18:50 PST

Advance directive completion rates remain poor in the ambulatory setting. The purpose of this study was to explore and contrast staff provider and resident physicians’ experiences with advance care planning (ACP) and to identify barriers to this process in the primary care setting. A 17-item survey was administered to staff primary care providers and categorical internal medicine residents. Staff providers were more likely to discuss ACP after prompting from patients’ family members (P < .02) or after a change in health status (P < .02) and were more likely to believe that non-physician members of the care team should counsel patients about ACP. The majority of respondents cited system-based barriers as major obstacles to ACP. Strategies aimed at systematizing the ACP process for both patients and providers are needed.

Influence of Malignancy on the Decision to Withhold or Withdraw Life-Sustaining Therapy in Critically Ill Patients

Cavallazzi, R., Hirani, A., Vasu, T. S., Pachinburavan, M., Kane, G. C. — Wed, 18 Nov 2009 17:18:50 PST

Purpose: To evaluate the influence of malignancy on the decision to limit life-sustaining therapy in the intensive care unit (ICU). Methods: At the day of patients’ admission to the ICU, we prospectively collected information on demographics, acute physiology and chronic health evaluation (APACHE) II score, and features related to malignancy. We retrospectively collected information on in-hospital survival and decision to withhold or withdraw life-sustaining treatment. Results: This study included 122 adult critically ill patients. After adjusting for age and APACHE II score, patients with malignancy had 3.02 (95% CI 1.19 to 7.62) higher odds of having life-sustaining therapy withdrawn or withheld as compared to patients without active malignancy. Conclusion: Our study showed that critically ill patients with malignancy are more likely to have their life-sustaining therapy withheld or withdrawn than those without malignancy after adjusting for severity of disease. This finding may be related to a perception that critically ill patients with malignancy have worse prognosis as compared with those without malignancy.

Buprenorphine for Neuropathic Pain--Targeting Hyperalgesia

Induru, R. R., Davis, M. P. — Wed, 18 Nov 2009 17:18:50 PST

Opioids are well known to relieve severe, acute, and chronic nociceptive pain, but neuropathic pain shows a relatively poor response to opioids. Buprenorphine, a partial mu and ORL-1-receptor agonist, kappa-delta receptor antagonist, interacts with different G proteins than potent mu agonists and hence is not cross-tolerant to standard opioids. Buprenorphine blocks central sensitization (hyperalgesia) that is commonly found with neuropathic pain. We present a patient with neuropathic pain and tactile allodynia in which buprenorphine alleviated the hyperalgesia to a greater extent than pain severity. We found buprenorphine to be effective in reducing hypersensitivity in neuropathic pain when pure mu agonists fail to produce a response or in individuals who are intolerant to pure mu agonists.

Diphenhydramine May Be Useful as a Palliative Treatment for Patients Dying With Parkinson's Disease and Tremors: A Case Report and Discussion

Gonzalez, F. — Wed, 18 Nov 2009 17:18:50 PST

Diphenhydramine is an antihistamine with anticholinergic properties, which has been used for the treatment of Parkinson disease (PD) prior to the development of newer agents with better side-effect profiles. However, most of these agents are given orally. Unfortunately, at the time of death, patients with paralysis agitans are no longer able to swallow and they can experience worsening of their tremors. We report the case of 1 patient with congestive heart failure (CHF) and PD who was unable to swallow and developed uncontrollable tremors 24 hours prior to death and whose tremors were successfully treated with diphenhydramine. We feel that in preimminent patients who cannot swallow or may not have perioral endoscopic gastrostomy (PEG)s or feeding tubes, parenteral diphenhydramine may be an appropriate palliative intervention to reduce tremors.

Family Support Services in Pediatric Palliative Care

Knapp, C. A., Contro, N. — Wed, 18 Nov 2009 17:18:50 PST

A fundamental premise of pediatric palliative care is that support is provided not only to the ill child but to the family as well. In doing so, a number of services may be offered to family members throughout the child’s illness, at the time of death and into bereavement, such as respite, counseling, expressive therapies, and bereavement support. Support may also be needed for the child’s peers at school, church, or on sporting teams. Evidence on family supportive care in pediatric palliative care research is scarce. The majority of existing studies are undertaken with bereaved parents. Although these studies are insightful, further information is needed to understand families’ needs along the illness trajectory and to determine whether unmet needs exist.

New Clinical End Points in Rehabilitation Medicine: Tools for Measuring Quality of Life

Abresch, R. T., Carter, G. T., Han, J. J., McDonald, C. M. — Wed, 18 Nov 2009 17:18:50 PST

Traditional clinical end points in rehabilitation medicine have centered on objective measures of human performance, including quantitative muscle strength testing, functional independence measurements (FIM), and timed motor performance (TMP). However, it is now increasingly recognized that health-related quality of life (HRQoL) is a valid clinical end point. Health-related quality of life is a broad concept involving an individual’s physical health, psychological state, personal beliefs, and interpersonal and social support relationships. The goals for this article are to show the value of performing HRQoL measurements and briefly describe methods used to assess quality of life (QoL).

Providing Care in an Unacceptable Environment

Wed, 18 Nov 2009 17:18:50 PST

A Son's Remembrance

Baxter, J. D. — Wed, 18 Nov 2009 17:18:50 PST

For a Peaceful Cancer Death in Egypt: Palliative Care IS NOT

Alsirafy, S. A. — Wed, 18 Nov 2009 17:18:50 PST

Heart Failure: ''Blowing Out Life's Little Candle''

Enck, R. E. — Fri, 09 Oct 2009 11:54:37 PDT

Perinatal Loss: Impacting Family Grieving and Nurse's Self-fulfillment

March, A. L. — Fri, 09 Oct 2009 11:54:37 PDT

Validity and Reliability of the Japanese Version of the Caregiver Reaction Assessment Scale (CRA-J) for Community-Dwelling Cancer Patients

Fri, 09 Oct 2009 11:54:37 PDT

Background: The aim of this study was to validate the Caregiver Reaction Assessment (CRA) among caregivers of community-dwelling advanced cancer patients in Japan. Methods: A cross-sectional questionnaire was administered to advanced cancer patients and their caregivers who were cared for at day hospices and home palliative care services. We translated the CRA into Japanese, and then verified factor validity, reliability, construct validity, concurrent validity, and known groups’ validity. To address construct and concurrent validity, we calculated Pearson’s correlation coefficient between the Japanese version of the CRA and the Burden Index of Caregivers (BIC). To address known groups’ validity, we used the t test or analysis of variance (ANOVA). Results: A total of 57 caregivers participated in the study. Five factors were extracted (‘‘impact on schedule,’’ ‘‘caregiver’s self-esteem,’’ ‘‘lack of family support,’’ ‘‘impact on health,’’ and ‘‘impact on finances’’) and reliability was good. Construct and concurrent validity among the subscales of the BIC were good. Regarding known groups validity, the subscale score of ‘‘impact on schedule’’ for the groups that cared 6 hours or more per day was higher than the other group (P = .04). Conclusion: The CRA-J is valid and reliable. This scale is useful for caregivers of cancer patients in Japan.

Application of the Sequential Organ Failure Assessment (SOFA) Score to Patients With Cancer Admitted to the Intensive Care Unit

Namendys-Silva, S. A., Texcocano-Becerra, J., Herrera-Gomez, A. — Fri, 09 Oct 2009 11:54:37 PDT

The aim of the current study was to describe the utility of the Sequential Organ Failure Assessment score in assessing the severity of organ dysfunction in patients with cancer before admission to the intensive care unit. This was a prospective cohort study performed from January to October 2007. The Sequential Organ Failure Assessment score was recorded before admission to intensive care unit. Two hundred patients were included. The Sequential Organ Failure Assessment score of patients having survived the intensive care unit stay was 3.44 ± 3.56 and of the patients no survivor’s was 9.35 ± 3.45. There were 89.5% of the patients who had 2 or more organ dysfunctions. The area under the receiver operating characteristic curve for score Sequential Organ Failure Assessment was 0.87. The mortality in the intensive care unit was 27.5%. The Sequential Organ Failure Assessment score was predictive for survival in intensive care unit when applied before admission.

The Incidence of Place of Death in Greek Patients with Cancer in 1995 and 2005

Fri, 09 Oct 2009 11:54:37 PDT

Purpose: To describe where (home or hospital) patients with cancer die in Greece, in 1995 and 2005. Methods: We used data from patients with cancer, who died in Greece in 1995 and 2005, and we studied the location changes of death in the 3 major geographical areas of Greece (Macedonia: North Greece, Central Greece, and Crete: South Greece). Results: In Central Greece and Crete, death incidences for 60 to 69, 70 to 79, and 80+ age groups decreased from 1995 to 2005. In Crete, in 1995, male and female death incidences for 80+ age group dying at home was higher than the corresponding one dying in hospital. Conclusion: It seemed that in Greece, more cancer patients are dying in hospitals. Geographical and socioeconomic criteria might affect the place of death of a patient with cancer.

Nursing Home Participation in End-of-Life Programs: United States, 2004

Resnick, H. E., Foster, G. L., Hickman, S. E. — Fri, 09 Oct 2009 11:54:37 PDT

The purpose of this report is to define the extent to which US nursing homes (NH) participate in end-of-life programs, using a nationally representative, cross-sectional sample of US NH. Data on EoL programs including Five Wishes, Last Acts, and Physician Orders for Life-Sustaining Treatment (POLST) were collected. In 2004, 17.2% of NH reported participating in 1 or more of these programs, with the largest proportion participating in POLST (13.3%) and smaller proportions in Five Wishes (5.6%) and Last Acts (4.2%). Nursing homes were more likely to participate in EoL programs if they also offered specialty programs and staff training for hospice, end-of-life, pain management, and dementia services. In 2004, fewer than 1 in 5 US NH participated in an EoL program. However, facilities that had EoL programs were more likely to have programs and staff training for services related to EoL care, a finding that suggests a clustering of these programs, services, and training. Provision of appropriate staff training may be a key to expanding EoL program participation in skilled nursing.

Improving Medication Error Reporting in Hospice Care

Boyer, R., McPherson, M. L., Deshpande, G., Weiss Smith, S. — Fri, 09 Oct 2009 11:54:37 PDT

The aims of this study are to determine the incidence of medication errors, characterize the type/severity of errors, and estimate the impact of an educational intervention on medication error processes in a hospice population. Medication errors from 2 hospice organizations were collected and coded for type of error/ outcome severity. The educational intervention included a 2-hour in-service and twice weekly reminders. A survey to assess participants’ change in knowledge and attitudes regarding medication error reporting through the study period and was administered at 3 different time points. Data analysis revealed that medication error reporting increased in one hospice program, that participants’ ability to correctly identify medication errors increased (P < .001), and awareness of medication errors in hospice care increased (P < .01) after the intervention.

Symptom Variability During Repeated Measurement Among Hospice Patients With Advanced Cancer

Lasheen, W., Walsh, D., Hauser, K., Gutgsell, T., Karafa, M. T. — Fri, 09 Oct 2009 11:54:38 PDT

Aim: In this prospective study, we explored symptom variability in patients with cancer during repeated measurements. Methods: Patients with cancer admitted to an inpatient hospice completed a daily questionnaire throughout their admission. The questionnaire consisted of 5 visual analogue scales (VAS) for anxiety, depression, nausea, pain, and sedation and 3 verbal rating scales (VRS) for depression, pain, and vomiting. Data from those who completed 5 consecutive days were used for the primary analysis. We used all available data points to compare VAS and VRS. An index was developed to assess for daily symptom variability. Results/Discussion: A total of 125 hospice inpatients were enrolled; 46 (38%) completed 3 consecutive daily questionnaires and 30 (24%), 5 days. We found (1) a statistically significant decrease in severity of symptoms present on admission, (2) new symptoms developed, (3) consequently overall symptom prevalence on days 1 and 5 appeared unchanged, (4) high daily symptom variability as demonstrated by the variability index and also changing daily symptom interrelationships, (5) demographic characteristics influenced symptom patterns on admission and subsequently, (6) severe pain predicted more frequent and severe symptom burden only on admission, (7) severe depression predicted more frequent and severe symptom burden on admission and thereafter, (8) VAS scores for depression and pain did not correspond with discrete VRS categories (mild, moderate, severe). Conclusions: (1) Symptom studies in advanced disease while difficult to conduct yield valuable information, (2) symptom relationships changed daily; strict timing of data collection is crucial for data analysis, (3) symptom monitoring following admission is an overlooked measure of risk assessment, (4) symptom prevalence studies alone for treatment follow-up may be misleading, (5) depression is an important predictor of symptoms and need to be more aggressively assessed and treated, (6) demographic characteristics may help identify symptom patterns and better direct treatment, (7) VRS rather than VAS was more reliable for assessing symptoms in hospice cancer patients.

End-of-Life Decision Making and Emotional Burden: Placing Family Meetings in Context

Radwany, S., Albanese, T., Clough, L., Sims, L., Mason, H., Jahangiri, S. — Fri, 09 Oct 2009 11:54:38 PDT

Background: Helping families make end-of-life care decisions can be challenging for health care providers in an intensive care unit (ICU). Family meetings facilitated by palliative care consult services (PCCS) have been recommended and found effective for improving support for families in these difficult situations. These services can be improved with a deeper understanding of factors associated with emotional burden in the aftermath of end-of-life decision making. Objective: This qualitative study seeks to provide a better understanding of family experiences and emotional burden surrounding end-of-life decision making. Participants and Methods: We conducted in-depth, semistructured interviews with 23 family members following the death of a loved one in the ICU. All participants had been involved in a PCCS-led family meeting concerning end-of-life decisions about their loved one. Methodology from grounded theory was used to analyze the content of transcripts and to build a theoretical model. Results: From the perspective of the family, decision making at the end of life is described within a theoretical model of salient experiences that are relevant to families’ emotional burdens. Three temporal stages were evident: (1) the illness experience, (2) decision making in the family meeting, and (3) the dying process. However, emotional burden in the form of lingering questions and resentment was more common when families reported having negative experiences during the final hospital stay. Conclusions: Supportive responsiveness from the PCCS for families who have experienced critical incidents or who have unanswered questions or resentment about treatment may be an important consideration to alleviate later emotional burden.

Illness Awareness in Hospice: Application of a Semi-Structured Interview

Fri, 09 Oct 2009 11:54:38 PDT

This study describes the results of a semi-structured interview to assess the illness awareness of cancer patients in Hospice. The results of this study are based on the interviews made in Rimini and Savignano sul Rubicone Hospices (n = 51). Psychologists evaluated illness awareness of the participants interviewed independently from the code system that is provided for the interview. According to the psychologists, 18 patients (35%) were aware, 11 patients (22%) were unaware, and 22 patients (43%) were aware with defense mechanisms. According to the code system of the interview, the results were the following: 18 patients (35%) were aware, 2 patients (4%) were unaware, and 29 patients (57%) were aware with defense mechanisms. Two participants had to be reassessed because of inconsistency in some factors. In conclusion, the data analysis underlined that the congruence of the 2 assessment methods was found in 33 of the 51 patients examined (65%) and that the degree of concordance was rather low ( = .46; 95% CI = 0.24-0.68).

Research in Pediatric Palliative Care: Closing the Gap Between What Is and Is Not Known

Knapp, C. A. — Fri, 09 Oct 2009 11:54:38 PDT

Pediatric palliative care provides physical and psychosocial care to children with life-limiting illnesses and their families. Services are provided by physicians, nurses, volunteers, and other providers in a myriad of settings. Over the past 30 years, a portfolio of research has amassed on palliative care. Yet, much remains unknown, particularly about pediatric palliative care. This article is the first in a series and it provides a general overview of what is known and unknown about the provision and need for pediatric palliative care. Subsequent articles will focus on specific topics such as decision making and support care. The purpose of this series is to inform and promote discussion about research in pediatric palliative care.

Review Article: A Model of Palliative Care for Heart Failure

Hupcey, J. E., Penrod, J., Fenstermacher, K. — Fri, 09 Oct 2009 11:54:38 PDT

The heart failure illness trajectory is both complex and unpredictable, which makes providing palliative care services to patients with heart failure a challenge. As a result, although services are needed, few tend to be offered beyond basic medical management. The traditional model of palliative care is typically based on palliative care being considered a system of care delivery most appropriate for patients with a predictable illness/death trajectory, such as terminal cancer. This type of model, which is based on the ability to predict the course of a terminal disease, does not fit the heart failure trajectory. In this article, we propose a new model of palliative care that conceptualizes palliative care as a philosophy of care that encompasses the unpredictable nature of heart failure.

Pain in Youths With Neuromuscular Disease

Engel, J. M., Kartin, D., Carter, G. T., Jensen, M. P., Jaffe, K. M. — Fri, 09 Oct 2009 11:54:38 PDT

To examine the prevalence and characteristics of pain in children with neuromuscular disease (NMD), 42 youths with NMD underwent a comprehensive evaluation including a detailed intake interview and structured questionnaire that included demographic and functional data. Youths who reported chronic pain were further queried about pain characteristics, locations, and intensity using an 11-point numerical rating scale and a modified Brief Pain Inventory (BPI). The sample consisted of 24 males (57%) and 18 females (43%), ages ranging from 9 to 20 years (M = 14.8, SD = 2.96). Participants included 14 (37%) with Duchenne muscular dystrophy, 6 (14%) with myotonic dystrophy, 2 (5%) with Becker dystrophy, 2 (5%) with limb-girdle dystrophy, 2 (5%) with congenital muscular dystrophy, 1 (2%) facioscapulohumeral, and 15 (36%) were classified as ‘‘other NMD.’’ Twenty-one (50%) were ambulatory; 26 (62%) used power wheelchairs/scooters, 9 (2%) used manual wheelchairs, 3 (.07%) used crutches/canes, and 1 (2%) used a walker. A total of 23 (55%) of the youths reported having chronic pain. Current pain intensity was 1.30 (range = 0-6), mean pain intensity over the past week was 2.39 (range = 0-7), mean pain duration was 8.75 hours (SD = 12.84). Pain in the legs was most commonly reported and 83% reported using pain medications. This study indicates that chronic pain is a significant problem in youths with NMD. These data strongly support making comprehensive pain assessment and management an integral part of the standard of care for youths with NMD.

Comfort Care Versus Euthanasia

Fri, 09 Oct 2009 11:54:38 PDT

Science and Religion: The How and the Why

Enck, R. E. — Fri, 21 Aug 2009 11:47:19 PDT

''How Could You Do This, Doctor . . .?''

Nabhan, C. — Fri, 21 Aug 2009 11:47:19 PDT

Managing Grief and Relationship Roles Influence Which Forms of Social Support the Bereaved Needs

Benkel, I., Wijk, H., Molander, U. — Fri, 21 Aug 2009 11:47:19 PDT

Social support is important during the bereavement period and influences which form of social support the grieving person needs. This study shows 2 different strategies for coping with grief which also revealed which form of social support the grieving persons needed depend on what they found difficult to manage. The coping strategies are called grief management and involve different strategies and the roles in the relationship with the diseased. Systematically monitoring the bereaved makes it possible to understand the strategies they use in the grieving process and to identify when these strategies are insufficient so professional support can be offered.

Three Lessons From a Randomized Trial of Massage and Meditation at End of Life: Patient Benefit, Outcome Measure Selection, and Design of Trials With Terminally Ill Patients

Downey, L., Engelberg, R. A., Standish, L. J., Kozak, L., Lafferty, W. E. — Fri, 21 Aug 2009 11:47:19 PDT

Improving end-of-life care is a priority in the United States, but assigning priorities for standard care services requires evaluations using appropriate study design and appropriate outcome indicators. A recent randomized controlled trial with terminally ill patients produced no evidence of benefit from massage or guided meditation, when evaluated with measures of global quality of life or pain distress over the course of patient participation. However, reanalysis using a more targeted outcome, surrogates’ assessment of patients’ benefit from the study intervention, suggested significant gains from massage—the treatment patients gave their highest preassignment preference ratings. The authors conclude that adding a menu of complementary therapies as part of standard end-of-life care may yield significant benefit, that patient preference is an important predictor of outcome, and that modifications in trial design may be appropriate for end-of-life studies.

Nurses' Perceptions of Factors Influencing Patient Decision Support for Place of Care at the End of Life

Murray, M. A., Wilson, K., Kryworuchko, J., Stacey, D., O'Connor, A. — Fri, 21 Aug 2009 11:47:20 PDT

Although patients have more choices about where to receive care as death approaches, they often need help with decision making. This study identified factors that influence nurses’ provision of decision support. A total of 22 nurses, from 3 health networks, participated in semistructured interviews. Overall, nurses held favorable attitudes toward providing decision support for place of care at end of life. Overlap between other professionals’ roles and nurses’ clinical experience affected nurses’ decision support behaviors. Although nurses considered decision support to be part of patient-centered care, they report a lack of skills, confidence, and tools to help them provide it. These findings confirm the need to develop practical postlicensure education strategies and ways to embed patient decision support tools into systems of care.

Influence of Prayer and Prayer Habits on Outcome in Patients With Severe Head Injury

Vannemreddy, P., Bryan, K., Nanda, A. — Fri, 21 Aug 2009 11:47:20 PDT

Objectives. The objective of the study is to evaluate the effect of prayers on the recovery of the unconscious patients admitted after traumatic brain injury. Material and Results. A retrospective study of patients with severe head injury was conducted. The Glasgow Coma Scale and Glasgow Outcome Scale scores were examined along with age, gender, smoking, and alcohol intake. There were 13 patients who received prayer and 13 who did not receive prayer during the hospital stay with almost identical mean Glasgow Coma Scale score. The prayer group stayed in the hospital for more days (P = .03). On multivariate analysis, patients’ age (P = .01), admission Glasgow Coma Scale score (P = .009), and prayer habits (P = .007) were significant factors. Conclusion. Patients with prayers habits recovered better following severe head injury. The role of intercessory prayer needs further studies in larger groups.

Patient Perceptions on the Use of Advance Directives and Life Prolonging Technology

Clements, J. M. — Fri, 21 Aug 2009 11:47:20 PDT

Introduction: Use of advance directives is underutilized despite the Patient Self Determination Act of 1990. This study was undertaken to determine use and opinions of advance directives by patients at a multidisciplinary.

Methods: Institutional Review Board—approved prospective survey of patients age 18 and over.

Results: Of 306 participants, 77 (25.2%) had a durable power of attorney and 45 (14.7%) had living wills. Of these, 226 (73.9%) responded that it was important to make health care wishes known to their doctor. Only 36 (15.9%) had done so. A total of 266 (86.9%) felt it was important to discuss health care wishes with their family and only 160 (60.1%) had done so.

Conclusions: While adequately describing use and attitudes toward advance directives, it is significant to note that patients believe their wishes for end-of-life care will be honored; however, they fail to take the necessary steps to guarantee this.

Guest at Hospice: Time for Consideration

Warren Stomberg, M. — Fri, 21 Aug 2009 11:47:20 PDT

This study focuses on daily life situation of terminally ill guests residing at a hospice. In the study, interviews were conducted with 9 such guests. Data were analyzed using a method similar to content analysis. Categories emerged that were related to aspects regarded as external and internal essentials for the well-being of the individual at the hospice. These essentials were as follows: encouragement from the staff, the alleviation of pain, a pleasant and calm atmosphere at the hospice, the significance of visits from relatives, the regret of not being able to take care of oneself, and time to reconcile to one’s life. These results not only show the need for close community with both family and staff but also the need for privacy to reflect on life.

Length of Survival in Hospice for Cancer Patients Referred From a Comprehensive Cancer Center

Younis, T., Milch, R., Abul-Khoudoud, N., Lawrence, D., Mirand, A., Levine, E. — Fri, 21 Aug 2009 11:47:20 PDT

This retrospective study examined 180 hospice patients referred from a comprehensive cancer center over 6 months in 2002 to (1) identify the variables associated with shorter length of survival (LOS) in hospice and (2) examine the LOS in hospice for those who previously participated in clinical trials and/or phase I studies. The median LOS in hospice for this cohort was 35 days. In multivariate analysis, low Palliative Performance Score (PPS) at hospice enrollment and male gender were associated with shorter LOS in hospice: males with low PPS had the shortest LOS while females with high PPS had the longest LOS. No correlation was found between the LOS in hospice and prior participation in clinical trials and/or phase I studies.

Reasons for Starting and Continuing to Volunteer for Hospice

Planalp, S., Trost, M. — Fri, 21 Aug 2009 11:47:20 PDT

The purpose of this study was to find out from hospice volunteers how they first heard of opportunities to volunteer, what motivated them to volunteer when they first began, and why they continue. A total of 351 volunteers from 3 states in the western United States participated in a questionnaire study. Three open-ended questions addressed how they heard of hospice, why they started, and why they continued. Their intentions to continue were also measured on rating scales. Responses to the open-ended questions were coded with acceptable intercoder reliability. Findings were that volunteers heard of opportunities through hospice and health care contacts, personal contacts, print and electronic sources, and other nonhospice organizations. They began volunteering primarily to be of service and because of a personal experience with the death of someone to whom they were close. Most volunteers chose to continue because they found it personally rewarding, helpful to others, or both, but many reported that they continue because of the quality of their own hospice organization and its staff. Demographic influences were noted but were generally small.

Multidisciplinary Family Meetings in the ICU Facilitate End-of-Life Decision Making

Fri, 21 Aug 2009 11:47:20 PDT

Objective: The aim of this study was to assess the feasibility of establishing a multi-disciplinary family meeting (MDFM) program and the impact of such a program on the end-of-life decision making in the setting of an ICU. Methods: During the study period MDFMs were scheduled for patients requiring mechanical ventilation for 5 or more days. The meeting followed a structured format. The pertinent details of the meeting as well as the treatment goals were recorded. Results: Twenty-nine patients were enrolled in this study. Thirty-five MDFM’s were held on 24 patients. A meeting could not be arranged for four patients. All meetings addressed patient’s diagnosis, prognosis and goals of care. Fifteen (52%) patients (9 of whom had metastatic malignancy) had life support withdrawal and died a mean of 4.8 + 4.2 days after the first family meeting. In the remaining 9 patients (3 with localized cancer and 6 with non-cancer diagnoses), the plan following the family meeting was to continue supportive care; all of these patients survived to hospital discharge. Conclusions: Proactive MDFM’s improve communication and understanding between patients’ family and the treating team and facilitates end-of-life decision making.

The Case for ''Palliative Dialysis''

Fri, 21 Aug 2009 11:47:20 PDT

Impact of Biopsychosocial Factors on Chronic Pain in Persons With Myotonic and Facioscapulohumeral Muscular Dystrophy

Fri, 21 Aug 2009 11:47:20 PDT

To assess the role of biopsychosocial factors in patients with type 1 myotonic and facioscapulohumeral muscular dystrophy (MMD1/FSHD) with chronic pain. Associations between psychosocial factors were found to be important in other samples of persons with pain and both psychological functioning and pain interference in a sample of patients suffering from MMD/FSHD. Prospective, multiple group, survey study of 182 patients with confirmed MMD1 and FSHD. Participants completed surveys assessing pain interference and psychological functioning, as well as psychosocial, demographic, and injury-related variables. Analyses indicated that greater catastrophizing was associated with increased pain interference and poorer psychological functioning, pain attitudes were significantly related to both pain interference and psychological functioning, and coping responses were significantly related only to pain interference. In addition, greater perceived social support was associated with better psychological functioning. The results support the use of studying pain in persons with MMD/FSHD from a biopsychosocial perspective, and the importance of identifying psychosocial factors that may play a role in the adjustment to and response to pain secondary to MMD/FSHD.

Physician Decision Making: An Observation

Sohoni, A. — Fri, 21 Aug 2009 11:47:20 PDT

An Overview of Constipation and Newer Therapies

Enck, R. E. — Tue, 16 Jun 2009 10:36:40 PDT

Respiratory Support in Oncology Ward Setting: A Prospective Descriptive Study

Tue, 16 Jun 2009 10:36:40 PDT

Background. Mechanical ventilation in cancer patients is a critical issue The present prospective descriptive study was designed (1) to assess the patient population needing respirator support in ward setting at a premier state-run oncology institute in India, (2) to observe and analyze the course of their disease while on respirator, and (3) to coordinate better quality of life measures in cancer patients at the institute based on the present study's outcomes.

Methods. Beginning from March 2005 to March 2006, all cancer patients who were connected to respirator in the wards were enrolled in the current study. Our anesthesiology department at the cancer institute also has primary responsibility for airway management and mechanical ventilation in high dependency units of oncology wards. Preventilation variables in cancer patients were assessed to judge the futility of mechanical ventilation in ward setting. Subsequently, patients were observed for disease course while on respirator. Final outcome with its etio-pathogenesis was correlated with predicted futility of mechanical ventilation.

Results. Over a period of 1 year, 132 (46 men and 86 women) cancer patients with median age 40 years (range 1-75 years) were connected to respirator in oncology wards. Based on the preventilation variables and indications for respirator support, right prediction of medical futility and hospital discharge was made in 77% of patients. Underestimation and overestimation of survival to hospital discharge was made in 10% cases and 13% cases, respectively.

Conclusion. Based on preventilation variables, prediction of outcome in cancer patients needing respirator support can be made in 77% cases. This high probability of prediction can be used to educate patients, and their families and primary physicians, for well-informed and documented advance directives, formulated and regularly revised DNAR policies, and judicious use of respirator support for better quality-of-life outcomes.

Does Caregiver Knowledge Matter for Hospice Enrollment and Beyond? Pilot Study of Minority Hospice Patients

Chung, K., Essex, E. L., Samson, L. — Tue, 16 Jun 2009 10:36:40 PDT

We examined the level of hospice knowledge of caregivers of minority elderly hospice patients and determined how it influences the hospice enrollment decision and the decision on the use of hospice services after enrollment. Based on qualitative analysis of medical records and interviews with caregivers of minority elderly hospice patients who received personal care from paid caregivers (eg, other than family caregivers), we found that hospice knowledge increased access to hospice among minority patients who otherwise would not opt for hospice or enroll too late for comprehensive hospice care services. Furthermore, the highest level of knowledge—acquired through caregivers' health care occupations—appears to influence hospice care after hospice enrollment. Caregivers with that level of knowledge made requests for changes in site of care and/or additional services that may enhance the quality of hospice care that their loved ones receive.

Prospective Evaluation of Transition to Specialized Home Palliative Care in Japan

Kusajima, E., Kawa, M., Miyashita, M., Kazuma, K., Okabe, T. — Tue, 16 Jun 2009 10:36:40 PDT

The aim of this study was to clarify patients' characteristics and the level of symptom management in the transition to specialized home palliative care, and to examine prospectively real-time evaluation of both terminal cancer patients and their families. This study was conducted at one of the largest institutions offering specialized home palliative care in Japan. We asked both the patient's and the family's health status at the initial assessment and 2 weeks later. One hundred sets of patients and their families were included in this study. Regarding patient characteristics at the time of referral to the specialized home palliative care service, patients referred from outpatient settings had more severe physical symptoms than patients referred from inpatient settings. The specialized home palliative care service could contribute to patients' symptom and families' psychosocial status.

Bioelectrical Impedance Phase Angle Changes During Hydration and Prognosis in Advanced Cancer

Tue, 16 Jun 2009 10:36:40 PDT

Introduction. We wished to determine bioelectrical impedance (BIA) correlates before hydration or changes during hydration and determine if these changes were prognostically important.

Methods and Materials. Fifty eligible patients underwent BIA measurements 3 consecutive days. Laboratory studies (electrolytes, creatinine, and hemoglobin) on day 1; weights and vital signs were recorded. Kaplan-Meier survival estimates were made at 30 and 60 days. Hazard ratios (HRs) based on Cox proportional hazards model were calculated.

Results. Weight loss was associated with shorter survival. A higher phase angle (PA) on day 1 predicted longer survival. Increased PA during hydration predicted shorter survival: increased weight during hydration predicted longer survival.

Discussion. Higher phase angle before hydration predicts poorer survival and, paradoxically, an increase in phase angle during hydration predicted poorer survival and preexisting intracellular dehydration, cachexia, or poor membrane function. Conclusions. Phase angle and weight during hydration predict survival in cancer.

Motivations of Hospice Volunteers

Planalp, S., Trost, M. — Tue, 16 Jun 2009 10:36:40 PDT

To recruit and retain volunteers, coordinators need to understand volunteers' motivations. In this study, 351 volunteers from 32 hospices in the western United States answered questions on a mailed survey about their motivations. The motivations reported were, in order of overall importance: to help others and learn, foster social relationships, feel better, and pursue career goals. Younger volunteers reported stronger career motivations, and retired and unemployed volunteers reported stronger social motivations. Volunteer coordinators should consider these motivations in communicating with potential and current volunteers, with special emphasis on compassion for those in need and the importance of helping, on fostering hospice volunteering as a learning experience, and in accessing and building social networks around hospice volunteering.

Medication Reconciliation in Hospice: A Pilot Study

Kemp, L. O., Narula, P., McPherson, M. L., Zuckerman, I. — Tue, 16 Jun 2009 10:36:40 PDT

Background: The Joint Commission required implementation of medication reconciliation processes by January 2006. Medication reconciliation is the practice of acquiring an accurate medication history at each transitional point of care. Potential for errors increases with inaccurate medication histories. This study determined the extent of medication reconciliation errors in hospice.

Methods: Patients were enrolled from 2 hospices in Maryland (January 2007). An initial medication history was completed by the nurse on hospice admission. The pharmacist did another medication history within 5 days of admission and compared the medication histories. All differences were reported as medication discrepancies.

Results: There were 504 medication discrepancies. Medication omissions occurred most commonly. All patients had at least 1 medication discrepancy (average 8.7 per patient). Overall, 190 drug interactions were identified; most were moderately severe. Conclusion: Terminal patients often use numerous medications increasing the risk of medication errors. Accurate medication histories reduce errors and potential for harm.

Beyond Polarization, Public Preferences Suggest Policy Opportunities to Address Aging, Dying, and Family Caregiving

Byock, I. R., Corbeil, Y. J., Goodrich, M. E. — Tue, 16 Jun 2009 10:36:40 PDT

Despite well-documented deficiencies and widespread suffering experienced by millions of elderly or ill Americans and their families, politicians rarely address end-of-life issues. Citizen Forums in New Hampshire surveyed 463 people regarding aging, serious illness, and caregiving. More than 80% indicated it was very or extremely important to have their dignity respected, preferences honored, pain controlled, and to not leave family with debt. Less than half strongly endorsed being kept alive as long as possible, prayed with or for, or having assisted-suicide available. Over 80% strongly endorsed palliative care requirements clinical licensure and reimbursement, expansion of family caregiver leave, respite care, and bereavement support. By avoiding actions which elicit strong divergence of opinion and focusing on actions on which consensus exists, public officials and candidates can respond to problems and improve care and experience for frail elders, dying Americans, and their families.

An Educational Program in a Pediatric Hospice Setting

Wood, I. — Tue, 16 Jun 2009 10:36:40 PDT

Canuck Place Children's Hospice, a family-centered pediatric hospice in Vancouver, Canada, provides family support and respite, pain and symptom management, and end-of-life care. One of the goals of pediatric hospice palliative care is to create an environment that supports a normal way of life and enhances quality of life. At Canuck Place, a unique school program for children with progressive life-threatening illnesses has been set up to meet this goal. This article describes the Canuck Place educational program, gives insights into the importance and challenges of providing a complete school experience, and discusses the expanded role of the teacher in the pediatric hospice setting.

Every Little Thing Is Gonna Be Alright

Pies, R. — Tue, 16 Jun 2009 10:36:40 PDT

Diversion of Opioid Pain Medications at End-of-Life

Tue, 16 Jun 2009 10:36:40 PDT

Review Article: Gynecological Disorders in Geriatric Emergency Medicine

Lewiss, R. E., Saul, T., Teng, J. — Tue, 16 Jun 2009 10:36:40 PDT

Emergency physicians must be competent in caring for elderly women because they constitute the fastest growing segment of the population in the United States. Familiarity with acute geriatric gynecologic issues is crucial to providing satisfactory health care for these patients with complaints relating to incontinence, pelvic floor dysfunction, and other gynecologic conditions. Vigilant suspicion for malignancy should be maintained in facilities that service patients without primary health care or insurance. This article provides a systematic approach to emergency department management of common geriatric gynecological conditions. Anatomical and physiological changes are discussed, as well as the geriatric pelvic examination, malignancy, urinary tract infection, incontinence, pelvic organ prolapse, and vulvovaginitis.

Letters to the Editor

Frank, G., Wolch, G. — Tue, 16 Jun 2009 10:36:40 PDT

The Challenges of Caring for an Incarcerated Patient

Zelaya, E. — Tue, 16 Jun 2009 10:36:40 PDT