Palliative Care最新文献

Pediatric end-of-life care (EOL care) entails challenging tasks for health care professionals (HCPs). Little is known about HCPs' experiences and needs when providing pediatric EOL care in Switzerland. This study aimed to describe the experiences and needs of HCPs in pediatric EOL care in Switzerland and to develop recommendations for the health ministry. The key aspect in EOL care provision was identified as the capacity to establish a relationship with the dying child and the family. Barriers to this interaction were ethical dilemmas, problems in collaboration with the interprofessional team, and structural problems on the level of organizations. A major need was the expansion of vocational training and support by specialized palliative care teams. We recommend the development of a national concept for the provision of EOL care in children, accompanied by training programs and supported by specialized pediatric palliative care teams located in tertiary children's hospitals.

Providing palliative care in Indigenous communities is of growing international interest. This study describes and analyzes a unique journey mapping process undertaken in a First Nations community in rural Canada. The goal of this participatory action research was to improve quality and access to palliative care at home by better integrating First Nations' health services and urban non-Indigenous health services. Four journey mapping workshops were conducted to create a care pathway which was implemented with 6 clients. Workshop data were analyzed for learnings and promising practices. A follow-up focus group, workshop, and health care provider surveys identified the perceived benefits as improved service integration, improved palliative care, relationship building, communication, and partnerships. It is concluded that journey mapping improves service integration and is a promising practice for other First Nations communities. The implications for creating new policy to support developing culturally appropriate palliative care programs and cross-jurisdictional integration between the federal and provincial health services are discussed. Future research is required using an Indigenous paradigm.

Despite significant advances in understanding the benefits of early integration of palliative care with disease management, many people living with a chronic life-threatening illness either do not receive any palliative care service or receive services only in the last phase of their illness. In this article, I explore some of the reasons for failure to provide palliative care services and recommend some strategies to overcome these barriers, emphasizing the importance of describing palliative care accurately. I provide language which I hope will help health care professionals of all disciplines explain what palliative care has to offer and ensure wider access to palliative care, early in the course of their illness.

Toward the end of life, older cancer patients with terminal illness often prefer palliative over life-extending care and also prefer to die at home. However, care planning is not always consistent with patients' preferences. In this article, discussions will be centered on patients' autonomy of exercising control over their bodies within the current biotechnoscientific paradigm and in the context of population aging. More specifically, the biopolitical strategy of medicine in the context of hospital-centered health care control and of the frail condition of cancer patients in the intensive care unit will be considered in terms of the bioethics of protection. This ethical principle may provide support to these patients by ensuring that they receive appropriate treatment of pain and other physical, psychosocial, and spiritual problems in an attempt to focus attention on the values of the ill person rather than limiting it to the illness.

Background: Physicians and patients frequently overestimate likelihood of survival after in-hospital cardiopulmonary resuscitation. Discussions and decisions around resuscitation after in-hospital cardiopulmonary arrest often take place without adequate or accurate information.

Methods: We conducted a retrospective chart review of 470 instances of resuscitation after in-hospital cardiopulmonary arrest. Individuals were randomly assigned to a derivation cohort and a validation cohort. Logistic Regression and Linear Discriminant Analysis were used to perform multivariate analysis of the data. The resultant best performing rule was converted to a weighted integer tool, and thresholds of survival and nonsurvival were determined with an attempt to optimize sensitivity and specificity for survival.

Results: A 10-feature rule, using thresholds for survival and nonsurvival, was created; the sensitivity of the rule on the validation cohort was 42.7% and specificity was 82.4%. In the Dartmouth Score (DS), the features of age (greater than 70 years of age), history of cancer, previous cardiovascular accident, and presence of coma, hypotension, abnormal PaO2, and abnormal bicarbonate were identified as the best predictors of nonsurvival. Angina, dementia, and chronic respiratory insufficiency were selected as protective features.

Conclusions: Utilizing information easily obtainable on admission, our clinical prediction tool, the DS, provides physicians individualized information about their patients' probability of survival after in-hospital cardiopulmonary arrest. The DS may become a useful addition to medical expertise and clinical judgment in evaluating and communicating an individual's probability of survival after in-hospital cardiopulmonary arrest after it is validated by other cohorts.

Agents used to control end-of-life suffering are associated with troublesome side effects. The use of dexmedetomidine for sedation during withdrawal of support in pediatrics is not yet described. An adolescent female with progressive and irreversible pulmonary deterioration was admitted. Despite weeks of therapy, she did not tolerate weaning of supplemental oxygen or continuous bilevel positive airway pressure. Given her condition and the perception that she was suffering, the family requested withdrawal of support. Despite opioids and benzodiazepines, she appeared to be uncomfortable after support was withdrawn. Ketamine was initiated. Relief from ketamine was brief, and its use was associated with a "wide-eyed" look that was distressing to the family. Ketamine was discontinued and a dexmedetomidine infusion was initiated. The patient's level of comfort improved greatly. The child died peacefully 24 hours after initiating dexmedetomidine from her underlying disease rather than the effects of the sedative.

Context: Accurate prognostication is important in oncology and palliative care. A multidisciplinary approach to prognostication provides a novel approach, but its accuracy and application is poorly researched. In this study, we describe and analyze our experience of multidisciplinary prognostication in palliative care patients with cancer.

Objectives: To assess our accuracy of prognostication using multidisciplinary team prediction of survival (MTPS) alone and within the Palliative Prognostic (PaP) Score.

Methods: This retrospective study included all new patients referred to a palliative care consultation service in a tertiary cancer center between January 2010 and December 2011. Initial assessment data for 421 inpatients and 223 outpatients were analyzed according to inpatient and outpatient groups to evaluate the accuracy of prognostication using MTPS alone and within the PaP score (MTPS-PaP) and their correlation with overall survival.

Results: Inpatients with MTPS-PaP group A, B, and C had a median survival of 10.9, 3.4, and 0.7 weeks, respectively, and a 30-day survival probability of 81%, 40%, and 10%, respectively. Outpatients with MTPS-PaP group A and B had a median survival of 17.3 and 5.1 weeks, respectively, and a 30-day survival probability of 94% and 50%, respectively. MTPS overestimated survival by a factor of 1.5 for inpatients and 1.2 for outpatients. The MTPS-PaP score correlated better than MTPS alone with overall survival.

Conclusion: This study suggests that a multidisciplinary team approach to prognostication within routine clinical practice is possible and may substitute for single clinician prediction of survival within the PaP score without detracting from its accuracy. Multidisciplinary team prognostication can assist treating teams to recognize and articulate prognosis, facilitate treatment decisions, and plan end-of-life care appropriately. PaP was less useful in the outpatient setting, given the longer survival interval of the outpatient palliative care patient group.

Introduction: The ability to estimate prognosis using administrative data has already been established. Research indicates that residents newly admitted to long-term care are at a higher risk of mortality. Studies have also examined mortality within 90 days or a year. Focusing on 31 days from assessment was important because it appears to be clinically useful for care planning in end-of-life; whereby, greater utility may come from identifying residents who are at risk of death within a shorter time frame so that advance care planning can occur.

Purpose: To examine risk of mortality within 31 days of assessment among long-term care residents using administrative health data.

Methods: Administrative data were used to examine risk of mortality within 31 days of assessment among all long-term care residents in Ontario over a 12-month period. Data were provided by the Canadian Institute for Health Information using the Continuing Care Reporting System (CCRS), Discharge Abstract Database (DAD), and the National Ambulatory Care Reporting System (NACRS).

Results: A number of diagnoses and health conditions predict death within 31 days. Diagnoses that hold an increased risk of mortality include pulmonary disease, diagnosis of cancer, and heart disease. Health conditions that lead to an increased likelihood of death include weight loss, dehydration, and shortness of breath. The presence of a fall within the last 30 days was also related to a higher risk of mortality.

Discussion: Long-term care residents who lose weight, have persistent problems with hydration, and suffer from shortness of breath are at particular risk of death. The presence of advanced directives also predicts death within 31 days of assessment.

Levorphanol (levo-3-hydroxy-N-methylmorphinan) is a step 3 opioid first developed in the 1940s as an alternative to morphine. Levorphanol belongs to the morphinan opioid series. Levorphanol has greater potency than morphine and is a potent N-methyl-d aspartate (NMDA) antagonist. Levorphanol interferes with the uptake of norepinephrine and serotonin, which makes it potentially useful for neuropathic pain. Glucuronidation changes Levorphanol to Levorphanol-3-glucuronide with excretion by the kidney. Levorphanol has a long half-life and may accumulate with repeated dosing. Levorphanol can be administered orally, intravenously, and subcutaneously. This article provides an update regarding the pharmacodynamics, pharmacology, and clinical efficacy of this often overlooked step 3 opioid.