Journal of palliative medicine最新文献

Background: Terminal dyspnea is a distressing symptom in advanced cancer patients. Although opioids are standard treatment, their effectiveness may differ between opioid-naïve and -tolerant patients. Objectives: To evaluate responses to opioid titration for terminal dyspnea and assess differences in palliative care physicians' perceptions of opioid effectiveness between opioid-naïve and -tolerant patients. Design: A pre-planned secondary analysis of a multicenter prospective cohort study. Setting/Subjects: Advanced cancer patients (n = 108) with moderate to severe terminal dyspnea and an Eastern Cooperative Oncology Group performance status of 3-4, receiving continuous parenteral opioid infusions, were included and categorized as opioid-naïve (n = 48) or opioid-tolerant (n = 60). Measurements: Opioid doses were titrated in four predefined levels within 48 hours, with effectiveness assessed 6 hours post-titration using the Clinician Global Impression-Improvement scale. Opioid ineffectiveness was defined as the need for continuous sedatives or death without dyspnea relief, with doses recorded as the parenteral morphine-equivalent daily dose. Results: The mean age was 72 years, and lung cancer was present in 43 patients (40%). Opioid-naïve patients showed a 100% response after 12 titrations, while opioid-tolerant patients exhibited a 68% response after 34 titrations. At death or one month after treatment, opioids were determined to be ineffective in 8.3% of opioid-naïve and 38% of opioid-tolerant patients (p < 0.001). Median doses at ineffectiveness were 15 mg (IQR = 7.5-23) and 36 mg (IQR = 14-200), respectively. Conclusions: Opioid-tolerant patients showed a lower-level response and were more likely to experience ineffectiveness than opioid-naïve patients. Larger studies are needed to confirm these findings and improve terminal dyspnea management.

Patients with cancer have a high rate of comorbid psychiatric disorders. While the exact prevalence of comorbid bipolar I disorder and cancer is unknown, given the worse health outcomes associated with siloed specialist care, increased knowledge of the co-management of patients with cancer and bipolar I disorder is needed in palliative care. This case highlights a need for awareness regarding the specific combination of olanzapine and samidorphan (Lybalvi), approved in 2021 for the management of bipolar I disorder. Samidorphan, an opioid antagonist, mitigates the metabolic side effects of olanzapine. Notably, patients with comorbid bipolar I disorder and cancer often have both significant anorexia and pain, making samidorphan less desirable, as, in addition to mitigating metabolic side effects, it can limit the efficacy of analgesia from opioids. A recommendation of transitioning to olanzapine only is discussed.

Background: Centralized locations in the electronic health record (EHR) improve access to advance care planning (ACP) information; however, the prevalence of documentation errors in these locations is unknown. Methods: In this cross-sectional study, we included primary care patients aged ≥65 years or ≥18 years with a serious illness. We verified errors using keyword queries and categorized them as "Patient Safety Errors" (e.g., ACP not in the centralized location) or "Noise Errors" (e.g., non-ACP in the centralized location). Associations between patient characteristics and errors versus no errors were evaluated using bivariate analysis. Results: Among 10,767 patients, 5374 (49.9%) had ACP in their EHR, and 495 (9.2%) of those had a verified error; 32.9% were Patient Safety Errors. Patients with errors were more likely to self-identify as from a minoritized population, be non-English speaking, and have a serious illness (p < 0.001). Discussion: Identifying documentation errors can help health systems create solutions for reliably scanning and storing patients' wishes and decreasing disparities.

Objective: To investigate two mechanisms, patient-level narrative richness and provider-patient empathy, of positive outcomes following Dignity Therapy, to focus provider training and intervention delivery. Background: Dignity Therapy is a brief reminiscence-based psychotherapeutic intervention designed to help seriously ill patients preserve dignity, reduce distress, and improve quality of life. Identifying mechanisms through which the therapy works can improve training and delivery of this increasingly popular intervention. Methods: Outpatients living with cancer (N = 203; M = 65.80 years; SD = 7.45 years; 66% women) from palliative care programs across the United States completed Dignity Therapy with a trained provider. Transcripts of their interview sessions were examined using interactional analyses to determine provider-level empathic communication. Transcripts were also content-analyzed for patient-level narrative richness. Changes in dignity, peaceful awareness of prognosis, and completion of existential tasks from pre- to postintervention were assessed. Results: The extent of narrative richness in patients' Dignity Therapy sessions was positively associated with post-test dignity (t = 3.09, p = 0.002) and completion of existential tasks (t = 2.65, p = 0.009) even when accounting for patient demographics. Providers' level of empathic communication did not affect patient outcomes at traditional significance levels. Results were not moderated by patients' symptom severity. Conclusions: Dignity Therapy benefits patients most when they richly engage in the process, narrating their life story and describing their legacy with elements of communion, meaning, and purpose. Future research might aim to follow up on forms of empathy or other provider behavior that elicit rich narratives during therapy.

Background: Expressions of self-blame are common in serious illness care, and determining how best to respond can be challenging, even for clinicians familiar with navigating strong emotion. Case Description: A 61-year-old woman with metastatic rectal cancer presented to the palliative care clinic to review surveillance imaging results, which demonstrated cancer progression. After processing this news, she expressed how her illness was adversely impacting her family, stating, "This is all my fault." The clinical team considered how to respond. Discussion: This case illustrates a common pitfall in responding to self-blame: the attempt to dismiss the patient's distress by quickly reassuring them that they did nothing wrong. Resisting the temptation to "fix" self-blame is challenging, yet essential, as empathically acknowledging this emotion and exploring its origins can aid in understanding the patient's concerns and priorities. We offer five strategies to support palliative care clinicians in responding effectively when patients and families invoke self-blame.

Background: The high suffering and symptom burden related to both lung cancer and nonmalignant pulmonary diseases calls for equal receipt of specialist palliative care (SPC) services. Objectives: To study the receipt of SPC in lung cancer and nonmalignant pulmonary diseases and the impact of SPC on the use of acute health care resources during the end-of-life. Design: A retrospective nationwide cohort study. Setting/subjects: All Finnish decedents who died of lung cancer (n = 2342) or nonmalignant pulmonary disease (n = 1571) in 2019 were searched from the registries of the Finnish Institute of Health and Welfare. Demographics, the use of SPC, the use of emergency department (ED), and hospitalizations were evaluated. Results: Contact with SPC services occurred in 27.8% and 9.1% of the patients with lung cancer and nonmalignant pulmonary disease, respectively (p < 0.001). During the last month of life, early SPC contact (>30 days before death) decreased the use of ED in lung cancer (46% vs. 63%, p < 0.001) and nonmalignant pulmonary disease (53% vs. 69%, p < 0.001) and reduced the number of hospitalizations in secondary care in lung cancer (31% vs. 59%, p < 0.001) and nonmalignant pulmonary disease (34% vs. 52%, p < 0.001). In both patient groups, early SPC contact was associated with lower need for ED and secondary care hospitalization during the last month of life, also in multivariable analyses. Conclusions: Contact with SPC services is more common in lung cancer than in nonmalignant pulmonary disease, although both groups have rather limited receipt of SPC. Early integration of SPC is recommended, as it has the potential to reduce burdensome acute health care use during the end-of-life in both patient groups.