Journal of palliative medicine最新文献

Background: Delirium is a common and distressing complication in terminally ill patients with advanced cancer, often impairing communication and decision-making, and diminishing the quality of the remaining life. Effective symptom management is essential; however, current clinical guidelines offer limited recommendations, and supporting evidence remains insufficient.

Objectives: This scoping review systematically mapped the existing literature on pharmacological and nonpharmacological interventions for delirium symptom management in terminally ill patients with cancer and identified gaps in the evidence base.

Methods: Following the framework proposed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines, we conducted a comprehensive literature search of PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ichushi-Web of the Japan Medical Abstract Society for studies published up to August 31, 2023. Subsequently, two updated searches were conducted using the same procedure with the first covering studies published between September 1, 2023, and September 30, 2024, and the second covering studies published between October 1, 2024, and September 30, 2025. Eligible studies evaluated interventions for delirium in adults with terminal cancer with a life expectancy of one month or less. Two reviewers independently screened the studies for inclusion.

Results: Of the 1640 articles identified, seven met the inclusion criteria including four randomized controlled trials on pharmacologic interventions, one randomized controlled trial on hydration, and two observational studies on opioid switching. All studies targeted terminally ill patients with advanced cancer and assessed the outcomes related to delirium symptom relief.

Conclusions: This review revealed that the literature addressing delirium symptom management in terminally ill patients with cancer is limited and heterogeneous. Further research is warranted to strengthen the evidence base and to inform clinical practice guidelines for the care of this vulnerable population.

Background: Simulation-based learning is increasingly integrated into medical education; however, the use of simulation in palliative medicine is generally limited to ad hoc communication skills and pain management. There is a recognized need for a structured approach to a simulation-based curriculum aligned with the unique challenges in complex symptom management and emergencies in palliative medicine specialty training.

Objectives: To identify and prioritize key clinical topics for a simulation curriculum for palliative medicine specialty training.

Methods: Using Kern's six-step approach to curriculum development, we conducted a two-phase needs assessment. Phase 1 was a survey of 101 palliative care practitioners to identify topics appropriate for more intensive training. Phase 2 applied the Delphi method with 46 participants to achieve consensus on priorities.

Results: Ten high-priority simulation topics emerged: dyspnea crisis, complex pain management, acute pain crisis, terminal agitated delirium, airway obstruction, existential distress, palliative sedation, intractable nausea and vomiting, opioid use disorder, and ventilatory support withdrawal. These aligned with competency-based and entrustable professional activities.

Conclusions: This study addresses the gaps in simulation use for complex and emergent clinical situations. Next steps include validation with residency program directors, mapping existing resources, and developing new content, supporting a collaborative approach to advancing palliative specialty education.

Palliative care (PC) aims to enhance quality of life and alleviate suffering in patients with advanced or degenerative diseases. Oral disorders (ODs) are common among PC patients, often impairing essential functions such as chewing, swallowing, and communication. The use of natural treatments for these conditions appears promising. This systematic review aimed to evaluate the efficacy, acceptability, and potential adverse events (AEs) and oral tolerability profiles of natural products used for managing ODs in patients undergoing PC. We conducted the review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered it in International Prospective Register of Systematic Reviews (protocol number: CRD42024591279). A comprehensive literature search was performed on multiple biomedical databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Cochrane Library), applying rigorous inclusion criteria. Included studies were assessed for quality using the Joanna Briggs Institute (JBI) Critical Appraisal Tools and the Oxford Centre for Evidence-Based Medicine levels of evidence. Out of 1075 identified records, 7 studies met the inclusion criteria, mostly randomized controlled trials (n = 5) with 522 PC patients. The studies had moderate to high methodological quality (mean = 88.4%, range = 64%-100%). Glycerol, Salvia officinalis, and peppermint mini ice cubes relieved oral symptoms. Glycerol gave rapid, short-lived relief; salvia improved dryness versus saline; peppermint cubes reduced dry mouth and thirst and were preferred. Cannabinoid trials did not prospectively assess ODs but were retained only as contextual evidence on oral AEs/tolerability and the feasibility of the oro-buccal route. Natural interventions may relieve xerostomia and improve comfort, but generalizability remains limited; future randomized trials with oral-specific endpoints, transparent dosing, and longer follow-up are required.

Introduction: Financial distress, a term used to encompass the negative consequences of the cost of medical treatment, can lead to delay of care, psychological distress, or even bankruptcy for patients and/or their families. Cancer is an expensive medical condition, and this distress is not routinely assessed. Methods: The primary objective of this study was to determine the frequency of high financial distress in patients with advanced cancer. Secondary objectives include determining the association between high financial distress with clinical and demographic characteristics. Primary outcome was based on the result of the InCharge Financial Distress/Financial Well-Being Scale (IFDFW), an eight-question survey with each question rated from 1 (overwhelming stress) to 10 (no stress at all). High financial distress was defined as a mean score of ≤4.0. Quality of life was assessed with Edmonton Symptom Assessment Scale-Financial and Spiritual Distress (ESAS-FS), Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy, and FACT-G surveys. Demographic data was collected from questionnaire and chart review. Results: One hundred and forty adult patients with advanced cancer were enrolled. The average patient age was in 50s, 67% were White, 12% Hispanic, 14% African American, and 4% Asian. Of the participants, 35/140 patients (25%) reported high financial distress. Patients with high financial distress were younger (55.1 vs. 59.3 years old, p = 0.04), less likely to be married (51.4% vs. 82.9%, p = 0.002), less likely to be working full time (23% vs. 31%, p = 0.001), and had lower annual household income (49% making less than $40,000 a year vs. 13%, p <0.001). There was a significant association between financial distress, symptom burden, and decreased quality of life. There was a strong correlation between the IFDFW score and single item 0-10 financial distress ESAS (0.6, p <0.001). Discussion: High financial distress is frequent among patients with advanced cancer. It was associated with younger age, nonmarried status, symptom severity, and decreased quality of life. Our findings suggest that financial distress should be monitored in supportive cancer care.

Background: Little is known about the impact of opioid safety initiatives (OSIs) on veterans with end-stage kidney disease on hemodialysis, a seriously ill population for whom balancing the benefits and harms of opioids can be challenging. Objective: To assess temporal trends and outcomes before and after the implementation of the Veterans Health Administration's (VA) OSI. Settings/Subjects: We conducted a cross-sectional study analyzing U.S. veterans who received VA-financed maintenance hemodialysis, either in the VA or under the VA Community Care program, from October 2009 to September 2019. Measurements: We assessed trends over time in the rates of outpatient opioid prescribing, moderate to severe pain, opioid overdoses, and use of nonpharmacological therapies. Data from VA, Medicare, and the United States Renal Data System were used. The unit of analysis was the patient-quarter. Results: We identified 44,557 veterans; 97.2% were male, 50.7% were White, and 61.6% were over age 65. The OSI was associated with a 10.28 percentage point (pp) reduction (95% confidence interval [CI]: -12.37, -8.19) in opioid prescribing and a 1.93 pp increase (95% CI: 0.30, 3.56) in the use of nonpharmacological therapies. The overdose rate decreased by 0.27 pp (95% CI: -0.54, -0.003), but the rate of reported moderate to severe pain increased by 3.21 pp (95% CI: 1.01, 5.40). These trends generally persisted among patients with different mortality risks. Conclusions: Our findings suggest that in the VA dialysis population, the VA OSI was associated with reductions in opioid use and modest decreases in opioid overdose but with limited uptake of nonpharmacological therapies and measurable increases in moderate to severe pain. These findings suggest the importance of an individualized patient-centered approach to opioid prescribing and research on nonpharmacologic alternatives in this population.

Introduction: Using time-limited trials of low-dose, sustained-release morphine to reduce chronic breathlessness to evaluate net effects may generate opioid withdrawal symptoms if medication is ceased. This sub-study of a larger randomized, placebo-controlled, double-blind trial aimed to evaluate if this occurred. Methods: People with modified Medical Research Council breathlessness scores of 3 or 4 and chronic obstructive pulmonary disease were eligible for a dose-increment titration phase (≤3weeks) and blinded extension (<26 weeks). Participants filled out the Subjective Opioid Withdrawal Scale (SOWS) daily for three days after ceasing/completing study medication (score 0-60; scores >20/60 severe opioid withdrawal). Active therapy was compared with placebo, and then, for people on morphine, comparisons between higher doses (24 mg, 32 mg), and lower doses (8 mg, 16 mg) and duration were undertaken. Results: Data were available for 126/156 participants (47% female, median age 73). Placebo or active therapy (Days 1-3) showed no statistically significant differences in SOWS scores (p > 0.05 for all days; Day 1 median 3/60 [IQR 1, 5] compared with 2/60 [IQR 1, 6], respectively; p = 0.475). Neither morphine duration nor dose were significantly different. Two people in the lower dose group in the extension phase had scores >20 for all three days. Individual symptoms that may draw clinical attention to morphine withdrawal include anxiety, a runny nose, perspiration, shaking, hot flushes, or nausea. Discussion: This preplanned substudy quantified risks of people experiencing self-reported symptoms of opioid withdrawal using a validated tool to inform discussions between clinicians and people with chronic breathlessness.

Ocular discomfort due to cancer treatments is common and typically treated with supportive care. For example, dry eye caused by some chemotherapies is managed with ocular lubricants. However, managing severe eye pain caused by tumor is challenging. We describe the case of a 63-year-old man with eye pain caused by basal cell carcinoma of the face with orbital invasion-an uncommon finding. Severe eye pain persisted, despite escalation of the patient's analgesic regimen. He was referred to an ocular oncologist by his palliative care physician and underwent surgical removal of the left eyeball and optic nerve (enucleation) with complete resolution of pain. We present this case to highlight an atypical case of basal cell carcinoma with orbital invasion as a cause of severe eye pain, to provide an overview of the nociceptive pathway of the eye, and to highlight palliative enucleation as a potential treatment option for similar cases.

Undocumented patients face structural constraints to accessing life-sustaining treatments in the subacute setting due to gaps in health care coverage. We present the case of a 38-year-old Spanish-speaking woman with short bowel syndrome, dependent on prolonged parenteral nutrition after critical illness, who faced additional challenges as an undocumented and uninsured patient. Despite medical stabilization and a consistent desire to pursue life-prolonging care, discharge planning was complicated by a health care system not designed to support individuals without legal status or insurance. This case illustrates the role of palliative care teams in bridging structural gaps through interdisciplinary collaboration and institutional advocacy.