Palliative medicine reports最新文献

Background: Community-based palliative care (CBPC) is only available in large cities in mainland China and little is known about who utilizes it.

Objectives: This study examined the characteristics, outcomes, and factors associated with place of death (PoD) among inpatient CBPC patients.

Design: This was a multicenter retrospective cohort study.

Settings/subjects: All patients admitted to the inpatient CBPC unit in four community health centers in 2021 in Shanghai, China, were included.

Methods: Characteristics and outcome data were extracted from electronic health records and paper version notes between September 4 and December 29, 2022. PoD was followed up on May 12, 2023. Data were analyzed using descriptive analysis and categorized using two-step clustering. Decision tree analysis was used to identify factors associated with PoD.

Results: The cohort admitted in 2021 included 290 participants (Age: 75.7 ± 12.7 years; Male: n = 155, 53.4%) including two children, with a mortality rate of 59.0% and a median length of stay (LoS) of 14 days upon December 29, 2022. The primary diagnosis for 80.3% of participants was tumor. Two clusters were identified. Cluster 1 was smaller than Cluster 2 (n = 45, 15.5% vs. n = 245, 84.5%) and dominated by noncancer participants (n = 37, 82.2%), whereas Cluster 2 included 91.8% (n = 225) tumor patients. Greatest significant differences in age, sex, marital status, education level, awareness of diagnosis and/or prognosis, mortality, LoS, and costs were found between the clusters. In total, 265 deaths derived from the cohort upon May 12, 2023, occur in inpatient CBPC units (75.5%), at home (18.9%), and in hospital wards (5.7%), influenced largely by participants' marital status and age.

Conclusions: Establishing contextualized inpatient CBPC services in more places nationwide that are tailored to different characteristics between cancer patients (i.e., younger and shorter inpatient stay) and noncancer patients (i.e., older and longer stay) is essential to maintain that more dying patients remain in their community.

Background and purpose: Dyspnea in patients with terminal cancer worsens near death, necessitating effective nonpharmacological management. Despite guideline recommendations, detailed studies on nonpharmacological nursing practices are scarce. This study aimed to elucidate nursing practices for dyspnea in patients with cancer based on monthly and weekly prognoses.

Methods: A multi-site cross-sectional study was conducted among nurses in 389 palliative care units in Japan. The study surveyed the frequency of direct care practices for dyspnea management (nurse-led intervention, multidisciplinary intervention, psychoeducational programs, breathing techniques, walking therapy, inspiratory muscle training, respiratory rehabilitation, yoga, acupressure, fan therapy, guided imagery, abdominal massage, aromatherapy, and a reduction in room temperature and humidity) in patients with cancer with monthly and weekly prognoses.

Results: Of the 389 invited units, 162 participated. From these, 2448 registered nurses were invited and 539 (22.3%) responded. Almost similar nursing practices were provided regardless of patient prognosis. Nurse-led intervention was the most frequently practiced, followed by room temperature and humidity reduction, multidisciplinary intervention, and fan therapy. Yoga, respiratory rehabilitation, and acupressure were rarely practiced.

Conclusion: Nursing practices for dyspnea are similar, irrespective of prognosis. Nurse-led interventions, reducing room temperature and humidity, multidisciplinary intervention, and fan therapy are frequently used for dyspnea in patients with cancer. Future studies should evaluate the effectiveness of these nursing practices.

Background: To address the need for short-term prognostic methods using objective measures, we developed a method to predict a 2- or 3-week prognosis using only six clinical tests (known as the WPCBAL score). However, the method has not yet been directly compared with globally accepted prognostic methods.

Objectives: This study aimed to clarify the usefulness of the WPCBAL score by comparing it with other prediction methods.

Setting/subjects: A prospective observational study was conducted with patients admitted to the palliative care unit of a Municipal Hospital in Japan between November 2017 and May 2021.

Measurements: The primary endpoint was each prediction method's accuracy-the WPCBAL score, Glasgow Prognostic Score (GPS), Palliative Prognostic Index (PPI), Palliative Prognostic Score (PaP), Delirium-Palliative Prognostic Score (D-PaP), and Prognosis in Palliative Care Study predictor models (PiPS-A, PiPS-B)-in predicting a prognosis at 2 or 3 weeks. The secondary endpoints were sensitivity, specificity, positive and negative predictive values, area under the receiver operating characteristic curve, and each prediction method's feasibility rate.

Results: In total, 181 patients were included in this study. For the 3-week prognosis, the PaP had the highest accuracy (0.746), followed by the D-PaP (0.735), WPCBAL (0.696), PPI (0.652), and GPS (0.575). For the 2-week prognosis, the PiPS-B had the highest accuracy (0.702), followed by the WPCBAL (0.696) and PiPS-A (0.641).

Conclusions: The WPCBAL score's accuracy in predicting a 2- or 3-week prognosis was comparable to that of commonly used prognostic methods, thus suggesting its usefulness as a short-term prognostic method.

Purpose: This study explores the use of nursing support among nurses for caregiver burden in family caregivers of terminally ill patients with cancer in palliative care units (PCUs).

Methods: Requests were sent to 389 institutions, and cooperation was received from 162 PCUs. Nurses at 162 PCUs were asked to participate in an Internet survey regarding nursing practices for caregiver burden in Japan. The frequency of six nursing support practices (extracted in a scoping review) was reported using a 5-point Likert scale.

Results: The response rate was 22.3% (539/2448). Support for reducing caregiver stress was the most frequently provided nursing support (mean Likert score: 2.41 for monthly prognosis and 2.42 for weekly prognosis). Psychological and educational support was mainly provided via non-face-to-face (telephone) (mean Likert score: 2.26 for monthly prognosis and 2.21 for weekly prognosis) and face-to-face methods (mean Likert score: 2.32 for monthly prognosis and 2.29 for weekly prognosis).

Conclusion: Nursing support was provided through telephone support and face-to-face interactions and aimed at reducing caregiver stress among nurses and family caregivers of patients with terminal cancer in PCUs. In this study, the trends in nursing support were similar for patients with a prognosis of weeks or months.

Background: Modified versions of the Objective Prognostic Score (mOPS) needs to be validated to reflect practical palliative care circumstances in Taiwan.

Objectives: We compared the abilities of an mOPS score of 1.5 or higher versus a Karnofsky Performance Status (KPS) score of 30 or lower to predict 2-week mortality in patients with advanced cancer in Taiwan.

Design: Observational study.

Setting/subjects: We performed a secondary analysis of an international multicenter cohort study of patients in East Asia. Participants were inpatients with advanced cancer in palliative care units (PCUs) in Taiwan.

Measurements: We compared the mOPS-B model, which does not require laboratory tests, with the KPS in a 2-week survival timeframe. We compared the accuracy of the prognostic models using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Calibration plots and net reclassification indices (NRI) for 2-week survival were compared between the two models. Differences in survival between the higher- and lower-scoring groups of each model were identified using the log-rank test.

Results: We included 317 patients, with a median survival of 14.0 days. The mOPS-B had a high sensitivity (0.82) and high AUROC value (0.69). By contrast, the KPS demonstrated good sensitivity (0.77) and an acceptable AUROC value (0.65) for predicting 2-week survival. The calibration plot did not demonstrate satisfactory agreement between the actual and predicted survival times in either the mOPS-B or the KPS groups. Our NRI was positive (absolute value: 22%), indicating that mOPS-B predicted 2-week survival better than KPS.

Conclusions: The mOPS-B may serve better than the KPS as a screening tool for admission to PCUs in Taiwan because it was more accurate at predicting 2-week survival.

Background: Caregivers in palliative care are tasked with supporting the patient in decision-making about treatment and care. However, how patients and their caregivers in palliative care support one another in the decision-making process is not fully understood.

Aim: To decipher how patients and caregivers in specialist palliative care support one another in decision-making about patient treatment and care.

Design: A qualitative study comprising semi-structured interviews. Data were thematically analyzed.

Setting/participants: Eleven patient-caregiver dyads (n = 22) were recruited from a large regional hospice service in Ireland providing specialist palliative care.

Results: Patients and caregivers felt they supported one another in decision-making by providing emotional support and coping as a unit. Open communication coupled with an understanding of each other's preferences helped patient-caregiver dyads navigate decision-making about the patient's treatment and care. Patients who made decisions independent of their caregiver did so to alleviate the burden for the caregiver and because they valued having control in decision-making about their care. Trust between the patient and caregiver made patients feel able to make decisions without counsel from their caregiver. Caregivers who advocated on behalf of the patient tended to make decisions with the patient. Shared decision-making comprised patient and caregiver making decisions together as a team with the opportunity to collectively re-examine and adjust their preferences for treatment and care.

Conclusions: This study identified that patients and caregivers in specialist palliative care can be emotionally supportive of one another in situations where they make decisions together about care and in situations where the patient makes decisions about care independent of their caregiver. These findings are relevant for health care professionals in palliative care who seek to promote emotional support between the patient and caregiver in discussions about treatment and care.

Background: Despite the risk of respiratory depression, benzodiazepines are often prescribed to patients receiving palliative care owing to their efficacy in symptom control. Opioids, which also cause respiratory depression, are often administered to patients with advanced-stage cancer. However, the additive effect of the two drugs has not been systematically analyzed.

Objective: This prospective observational study aimed to determine the respiratory effects of coadministration of benzodiazepines and opioids in terminally ill patients with cancer.

Methods: The respiratory variables (primary endpoint) and activity index (ACI) (secondary endpoint) of 24 patients were assessed using a continuous noncontact, nonrestraining vital sign monitor placed under the legs of the bed.

Results: The respiratory rate (RR) changed from 12.0  ±  3.9/min to 10.3  ±  3.3/min (n = 24, p = 0.0005) following administration of the first dose of benzodiazepine in addition to regular opioid treatment, indicating no difference (p > 0.83) from the decrease in the RR observed on the previous day at the same time (12.1  ±  3.3/min to 10.3  ±  3.4/min). No increase in apnea-hypopnea frequency and respiratory irregularity or no decrease in respiratory size was observed. The ACI showed a significant decrease following the administration of benzodiazepine, suggesting remission of the symptoms. The effect of five repeated doses of benzodiazepines in nine patients showed no significant change in the respiratory variables compared with the first dose.

Conclusion: Addition of single or consecutive benzodiazepine-type drugs at clinically useful dose in patients receiving palliative care for cancer with opioid analgesics, readily exposed to respiratory depression, was observed with a decreased RR similar to the decrease observed during sleep with opioid alone.

In 2022, a JAMA systematic review of 342 high quality studies called for spiritual care to be a routine part of care for patients with serious illness. The review's multidisciplinary panel made several recommendations for addressing patients' and families' spiritual concerns. Despite these evidence-based recommendations, there are no clinical guidelines that inform when and how such spiritual care should be provided. We propose convening a multi-disciplinary workgroup to generate specific and actionable guidelines for incorporating spiritual care in serious illness care. We suggest three workgroup priorities: (1) determining best approaches to identifying patient and family members' spiritual care needs; (2) developing ways to integrate chaplains into routine clinical care; and (3) determining best approaches to communicate availability of spiritual care. Developing these guidelines is an imperative next step to deliver high quality, person and family-centered care.

Background: The "surprise question" (SQ) ("Would you be surprised if this patient died in the next 12 months?") is the most frequently used screening tool in emergency departments (EDs) to identify patients with poor prognosis and potential unmet palliative needs.

Objective: To test and compare the accuracy of the SQ between emergency nurses (ENs) and emergency physicians (EPs) in predicting long-term mortality among older patients (OP) in the ED.

Design and setting/subjects: A prospective cohort study of OPs (≥75 years) conducted in two Belgian EDs. EPs and ENs answered the SQ for the patients they cared for. Positive SQ (SQ+) was defined as a "no" answer. One-year mortality was assessed by phone call.

Results: EPs and ENs both answered the SQ for 291 OPs (mean age 83.2 ± 5.4, males 42.6%). The SQ was positive in 43% and 40.6%, respectively. Predictive values were similar in both groups: sensitivity, specificity, c-statistics, negative predictive value, and positive predictive value were 0.79 (0.66-0.88), 0.68 (0.62-0.76), 0.69 (0.63-0.75), 0.92 (0.86-0.96), and 0.4 (0.31-0.50), respectively, for EPs and 0.71 (0.57-0.82), 0.69 (0.62-0.75), 0.69 (0.63-0.75), 0.89 (0.83-0.93), and 0.41 (0.31-0.51), respectively, for ENs. SQ + was associated with a higher mortality risk in both group (EPs hazard ratio: 3.2 [1.6-6.7], p = 0.002; ENs hazard ratio: 2.5 [1.3-4.8], p = 0.006). The survival probability was lower when both EPs and ENs agreed on the SQ+ (p < 0.001).

Conclusion: The SQ is a simple tool to identify older ED patients at high mortality risk. Concordant responses from EPs and ENs are more predictive than either alone.