Journal of palliative medicine最新文献

Background: Palliative care is essential yet underutilized in Canada. Inconsistent definitions and fee codes across provinces/territories hinder effective comparative analysis.

Aim: Explore palliative care definitions and fee codes in Canada by examining the provincial/territorial schedules of benefits.

Design: We conducted a narrative review of provincial/territorial schedules of benefits, focusing on palliative care definitions and fee codes. Qualitative comparative analysis was performed on the definitions, and descriptive statistical analysis was conducted on the fee codes.

Setting/participants: The study reviewed schedules of benefits from 11 Canadian provinces and territories, excluding Quebec and Nunavut.

Results: About 7/11 (64%) provinces/territories published definitions for palliative care, typically characterizing it as terminal, focusing on comfort, and providing a time-based prognosis. The number of specific palliative care fee codes varied from 4 to 32.

Conclusions: There is substantial variability in the definition and fee codes used for physician-delivered palliative care across Canada. A standardized national framework for palliative care definitions and fee codes could improve access and care delivery.

Background: Sudden unexpected death can occur even among patients with advanced cancer receiving hospice and palliative care. How bereaved families perceive this remains unclear.

Objectives: To investigate the prevalence of sudden unexpected death from bereaved family perspectives, the level of agreement with physician perspectives, and their association with bereaved families' mental health.

Design/setting/subjects: We analyzed longitudinally linked data from a prospective cohort of advanced cancer patients in 23 palliative care units in Japan and a nationwide survey of bereaved families.

Measurements: Sudden unexpected death was assessed using previously reported definitions: (1) "surprise death" and (2) "rapid decline death," evaluated from both physician and bereaved family perspectives, and (3) "performance status-defined sudden death," evaluated only by physicians. Agreement among definitions was analyzed using kappa statistics. Bereaved families' mental health was evaluated using the Patient Health Questionnaire-9.

Results: Among 611 cases, "surprise death" and "rapid decline death" were more frequent from bereaved family (46.5% and 51.2%, respectively) than physician (8.2% and 16.5%, respectively) perspectives. Agreement between family and physician perspectives was low (κ = 0.04-0.14). The bereaved family-perceived "rapid decline death" was significantly correlated with depression (adjusted odds ratio = 1.75, p = 0.028), whereas physician-perceived sudden unexpected death showed no significant correlation.

Conclusions: Compared with physicians' perspectives, bereaved family members perceive death to be sudden or unexpected more frequently and differently, and their perceptions are associated with postbereavement mental health. Further research is needed to explore strategies to improve communication and support families' psychological preparedness when a patient's death may be sudden and unexpected.

Background: Palliative care patients often experience sarcopenia, which can cause overestimation of kidney function by creatinine-based estimated glomerular filtration rate (eGFR) and inappropriate drug dosing. Data on cystatin C (CysC) use are scarce.

Objectives: To examine intra-individual differences between creatinine- and CysC-based eGFR in palliative patients and assess the frequency of renally eliminated drugs prescribed.

Design: Retrospective, single-center cohort study.

Setting/subjects: All patients admitted in 2023 to the palliative care unit of the University Hospital Zurich, Switzerland. Of 206 patients, 178 had eGFR data, and 144 with consent were included.

Measurements: Data including creatinine, CysC, and prescribed medications were extracted from electronic records. eGFR was calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2009 (creatinine) and CKD-EPI 2012 (CysC, combined). Intraindividual discrepancies >15 mL/min/1.73m² were defined as clinically relevant.

Results: Paired values were available for 85 patients; 53% showed clinically relevant discrepancies (median 17 mL/min/1.73m²). In 22% of patients the discrepancy exceeded 30 mL/min/1.73m². Diabetes was the only factor associated with differences. Acute kidney injury (AKI) occurred in 32% and was strongly linked to mortality, whereas discrepancies were not. Patients received a median of 19 drugs; of the 20 most frequently prescribed, 7 were renally eliminated. Over one-third with relevant discrepancies received two such drugs.

Conclusions: Clinically relevant eGFR discrepancies are common in palliative care patients and may cause misclassification and dosing errors. CysC testing should be used selectively when prescribing renally eliminated drugs with toxicity risk, underscoring the need for individualized prescribing and prospective validation.

Background: Psychospiritual distress (PSD) causes profound suffering in people with serious illness, yet treatment options are few and evidence of their efficacy is modest. Although high-level evidence is limited, decades of preliminary research suggest that psychedelic-assisted psychotherapy (PAP), including ketamine-assisted psychotherapy (KAP), may alleviate the anxiety, depression, and existential distress associated with PSD. However, clinical examples and published implementation frameworks for integrating these interventions into palliative care are scarce. To help bridge this gap, we describe the development and delivery of a palliative care-embedded KAP program at an academic medical center.

Objective: To describe the design, implementation, and clinical experience of Pal-KAP, a safety-centered and equitably accessible KAP program embedded in outpatient palliative care.

Methods: We detail the program's origins, team composition and training, operational model, patient selection and consent process, session structure, safety protocols, and financial model. We summarize patient characteristics and treatment patterns and share illustrative clinical vignettes from the program's first 28 months.

Results: Between May 2023 and September 2025, 59 patients were referred for Pal-KAP screening; 43 met the eligibility criteria, and 30 elected to participate. Patients (age 19-76, mean 53) completed a median of 1.5 medicine sessions (range 1-5). Most had cancer (80%) or neurological disease (13.3%). Ketamine dose averaged 0.93 mg/kg intramuscularly, with minor adverse effects (anxiety, headache, nausea, insomnia, dizziness) and no serious adverse events.

Conclusion: To our knowledge, this is the largest published cohort of KAP in an academic palliative care context. Our Pal-KAP experience suggests that KAP can be delivered safely and ethically, providing a practical blueprint for programs exploring innovative ways to address PSD.

Pediatric palliative care (PPC) supports complex decision-making for seriously ill children. This process requires compassionate and skillful communication with a child's caregivers, most often the parents. When a caregiver is incarcerated, there is an additional layer of complexity in navigating these difficult conversations. We present the case of an infant with complex congenital heart disease, severe neurological impairment, and respiratory failure whose parents were faced with the decision to pursue life-prolonging medical care with a tracheostomy or end-of-life care with compassionate extubation. We describe how our interdisciplinary team recognized and navigated the teams' biases, knowledge gaps, and logistical complexities to provide optimal decisional support to parents affected by incarceration. We aim for this case to raise awareness of an underexplored issue in the literature.

Background: Delirium affects most patients with advanced cancer and is a major source of distress, especially in its hyperactive subtype. Pharmacologic options are limited for patients who cannot take oral medications.

Objectives: To evaluate the effectiveness and safety of a transdermal blonanserin patch for managing hyperactive delirium in patients with advanced cancer admitted to a palliative care unit.

Design: Retrospective observational study.

Settings/subjects: Consecutive patients with advanced cancer admitted to a palliative care unit in Japan between July 2023 and July 2025. Among 60 patients exhibiting agitation (Richmond Agitation-Sedation Scale-Palliative Version [RASS-PAL] ≥ +1), 21 received a 40-mg blonanserin patch. Eighteen patients who completed the 7-day assessment were analyzed.

Measurements: The primary endpoint was the change in RASS-PAL score from day 0 to day 7. Safety events and the need for additional antipsychotics were recorded.

Results: The median RASS-PAL score decreased from 2.0 to 0.5, and the mean score decreased from 1.9 to 0.6 (p = 0.0019). One patient developed reversible excessive sedation. No extrapyramidal symptoms, neuroleptic malignant syndrome, or cardiopulmonary events occurred. The median time from patch initiation to death was 24 days. Five patients required rescue antipsychotics, and no recurrence of the initial severity of delirium was observed.

Conclusions: The transdermal blonanserin patch appears to be an effective and well-tolerated option for hyperactive delirium in patients with advanced cancer who cannot take oral antipsychotics. Larger prospective studies are warranted to confirm effectiveness and guide optimal use.

Background: Health care professionals (HCPs) in home palliative care (PC) face emotionally demanding situations, increasing their risk of burnout, compassion fatigue, and reduced work engagement. Clinical supervision is a recommended supportive intervention, but longitudinal evidence is limited.

Objectives: To assess, over 2 years, the professional quality of life-burnout, secondary traumatic stress (STS), and compassion satisfaction (CS)-of HCPs providing home PC and receiving monthly clinical supervision. Secondary aims were to evaluate coping strategies and work engagement.

Design: Nonprofit longitudinal study with assessments at baseline, after one year, and after two years.

Setting/subjects: In total, 285 HCPs from 20 multidisciplinary teams across 11 Italian regions. Analyses focused on 112 participants who completed all assessments and attended ≥80% of supervision sessions.

Measurements: Professional Quality of Life Scale, Coping Inventory for Stressful Situations, and Utrecht Work Engagement Scale questionnaires were administered. Data were analyzed using generalized estimating equation models and repeated measures of general linear models.

Results: At baseline, HCPs reported medium-high CS, low-medium burnout, and STS, with no significant changes over time. Task-oriented coping was predominant and stable. Work engagement remained moderate. Burnout positively correlated with age and years of PC experience and negatively with work engagement.

Conclusion: Regular clinical supervision may help preserve the professional quality of life of PC HCPs, maintaining stable levels of burnout, CS, and work engagement over time. Findings support integrating a supervision program within a wider organizational strategy aimed at ongoing monitoring and promoting staff well-being.