Journal of palliative medicine最新文献

Background: Ketamine is an N-methyl-D-aspartate receptor antagonist traditionally used for dissociative sedation that has also been used for the treatment of pain. Ketamine can have a higher bioavailability when administered intranasally. Objective: To present a case in which intranasal (IN) ketamine was used for unpredictable, episodic, cancer-related neuropathic pain. Case Presentation: We present a 49-year-old patient with metastatic adenocarcinoma of the lung who presented to our outpatient palliative care clinic with uncontrolled severe episodic neuropathic pain of the lower extremity. Case Management: We prescribed compounded racemic ketamine 20-30 mg intranasally as needed at the onset of severe episodes of breakthrough pain, in addition to scheduled use of oral methadone and a buprenorphine patch for long-acting pain management. Case Outcome: The patient reported a decrease in frequency, intensity, and duration of episodic breakthrough pain with use of IN ketamine without any reported negative adverse effects. Conclusion: Low-dose compounded racemic IN ketamine may be a useful and safe adjunct in alleviating severe breakthrough pain in cancer patients in the outpatient setting.

Background: The 2022 ACC/AHA/HFSA guidelines recommend the integration of palliative care (PC) in heart failure (HF) management. The potential of telemedicine to improve PC utilization among HF patients remains an area of active research. However, the factors influencing its utilization remain poorly understood. Objective: This study aimed to evaluate patient-level factors associated with tele-palliative care consultation (tele-PCC) utilization among HF patients admitted to a large health care system. Methods: A retrospective cross-sectional observational analysis was conducted on 31,055 patients admitted to University of Pittsburgh Medical Center hospitals with HF between 2017 and 2022. Multivariable logistic regression was used to identify the predictors of tele-PCC utilization, and results are expressed as odds ratios (OR) and 95% confidence intervals (CI). The accuracy of the multivariate model was assessed using the area under the curve (AUC). Results: Patients aged <50 (OR: 15.12; 95% CI: 7.73-29.56; p < 0.001) and those with higher Charlson Comorbidity Index scores (OR: 1.130; 95% CI: 1.05-1.22; p = 0.002) were more likely to access tele-PCC. Patients with higher Area Deprivation Index (ADI) scores (ADI <20 vs. (61-80) [OR]: 0.43; 95% CI: 0.18-0.99; p = 0.048, ADI <20 vs. >80 [OR]: 0.40; 95% CI: 0.18-0.93; p = 0.032), closer to a tertiary hospital (<20 miles: OR: 0.21; 95% CI: 0.14-0.33; p < 0.001), and those receiving care in the pre-COVID-19 era (OR: 0.06; 95% CI: 0.03-0.11; p < 0.001) were less likely to utilize tele-PCC. No significant differences were observed based on gender, insurance type, or race. The multivariate model demonstrated strong predictive ability (AUC = 0.8996). Conclusions: We observed greater tele-PCC utilization among younger patients and those with higher comorbidity burden and during the postpandemic era, while socioeconomic factors such as those with higher ADI continue to have limited access. These findings underscore the potential of telemedicine as a tool to enhance PC delivery to HF patients.

Background: The Department of Vermont Health Access (DVHA) administers Medicaid and currently reimburses for institutional palliative care (PC) for both adults and children. While home-based palliative care (HBPC) is reimbursed for pediatric beneficiaries, HBPC for adults is an uncovered service. Objective: To assess the need for adult HBPC Medicaid coverage and evaluate barriers to providing HBPC services from the perspective of local medical professionals and home health agencies (HHAs) in the state of Vermont. Design: Qualitative and descriptive study. Setting/Subjects: Six clinicians from Vermont, United States, were individually interviewed. DVHA recruited 10 HHA representatives to participate in a focus group and 1 HHA representative who was unable to attend but participated in a separate interview. All participants (n = 17) received an information packet with a proposed PC service package developed prior to participation. Measurements: Recordings of the interviews and focus group were transcribed and analyzed using thematic content analysis with NVivo software (version 14). The independent coders reviewed the transcripts and identified key themes and subthemes. Results: Four overarching themes were identified: (1) Treatments, Purpose, and Quality of Care; (2) Interdisciplinary Team, Staffing, and Referrals; (3) Education, Communication Barriers, and Defining PC; and (4) Accessibility and HHA Financial Considerations. Conclusions: Overall, clinicians and HHA representatives suggested that HBPC may provide benefit for patients through enhanced quality of life, but many believe that further education and staffing are necessary to appropriately deliver these services. Further research into Medicaid reimbursement models will be helpful to assess the feasibility of HBPC delivery.

Insomnia is a common disorder among persons with cancer that depletes physical and emotional resources needed to cope with cancer and its treatment. Acceleration Resolution Therapy® (ART®) is a trauma-based psychotherapeutic intervention that uses a mind-body approach to process memories and experiences to positively influence current thought patterns, emotions, and behaviors. ART has been shown to improve sleep in veterans with posttraumatic stress disorder, but there is little evidence evaluating ART as an intervention for insomnia. The purpose of this article is to describe our clinical experience with using ART for the treatment of insomnia in cancer. We describe two cases of patients with advanced or relapsed cancer who were treated for insomnia with a single session of ART. Both participants showed improvements in sleep after a single ART session. One participant experienced improvements in sleep duration. The other participant was able to consistently sleep through the night when she had not been able to do that in the past. ART may be a nonpharmacological option for management of insomnia among persons with cancer, though more research evidence is needed.

Patient sexuality and intimacy comprise important dimensions of quality of life (QOL), making them essential topics for palliative care (PC) clinicians to address. Created with interprofessional input from PC, urology, gynecology, sexual health, oncology, psychiatry, psychology, nursing, and social work, this article offers 10 high-yield, evidence-based tips to better equip PC clinicians to address sexuality and intimacy for patients with serious illness. These tips highlight skills such as opening discussions, assessing concerns through a biopsychosocial model, and thinking through appropriate interventions to improve QOL.

Background: Clinical teams face many barriers to communicating with the parents/caregivers of patients experiencing an acute decline. Outside of these time-critical situations, clinicians often can iteratively assess and cultivate prognostic awareness of the patient and parents/caregivers and elicit values and goals over multiple conversations. However, in emergent circumstances, a modified approach to support prognostic awareness is necessary. Methods: We developed a clinical practice guideline for time-critical decision making through consensus with an interprofessional group. Results: Our proposed strategy starts with a concise statement naming the situation and urgent decision to be made, followed by an outline of the medical options with individualized clinical contextualization for the child and/or parents/caregivers. Finally, incorporating responses (verbal and nonverbal) from the parents/caregivers, recommendations for next steps are offered, with a check-in to ensure agreement with the recommendation(s). Conclusion: This framework is intended to supplement, not replace, existing guidelines for eliciting values and making medical recommendations in time-critical situations.

Background: Nearly 50,000 people aged 65 and older are living with dementia in Nevada. The number of Nevadans living with dementia is projected to increase to 65,000 or more by 2025-the third largest growth rate in the United States. Objective: We examined differences in discharge to hospice among racial and ethnic minority groups living with dementia and utilizing health care in Southern Nevada. We also explored differences by other demographic and health care-related characteristics. Methods: Data analyzed were from comprehensive health care data records from multiple health care settings in Nevada and for all causes for the years 2013-2021. Bivariate analysis and multiple logistic regression were utilized to examine differences in discharge to hospice by racial and ethnic minority groups accounting for demographic and health care-related characteristics. Results: During 2013-2021, 131,900 dementia-related health care encounters in Southern Nevada from both inpatient and outpatient visits occurred. Only 6% (n = 8,490) of dementia health care utilizers in Southern Nevada were discharged to hospice, which differed by racial and ethnic minority groups (p < 0.001). Black, Asian Pacific Islander, and Hispanic/Latino older adults living with dementia had between 15% to 26% lower odds of being discharged to hospice compared with their White counterparts. Age, gender, health insurance type, and inpatient encounters and year were also significantly associated with being discharged to hospice. Conclusions and Relevance: Findings from this study highlight the need to better understand potential disparities in access to hospice care among racial and ethnic minority communities living with dementia. Interventions to improve equitable access to hospice care among diverse populations in Southern Nevada should be explored.