Palliative medicine reports最新文献

One of the more challenging aspects of specialty level training in any medical fellowship is learning to communicate mindfully and effectively with patients and families in the face of serious illness. For the past five years, our accredited Hospice and Palliative Medicine (HPM) fellowship program has been integrating the "verbatim"-an exercise with a long and integral history in the training of health care chaplains. Verbatims are word-for-word accounts of a clinician's encounter with a patient and/or the patient's family. The verbatim serves as a formative educational exercise offering a method to hone one's clinical skills and competencies, while providing a unique space to practice self-awareness and self-reflection. Although sometimes difficult and intense for the fellow, we have found this to be a helpful exercise in improving the fellow's ability to make meaningful connections with patients and leading to improved outcomes of communication episodes. This potential growth in self-awareness supports both resiliency and mindfulness, which are essential skills for longevity and reduction of burnout risk in the field of HPM. The verbatim invites all participants to reflect on their own participation in facilitating whole person care to patients and families. Out of the six HPM milestone metrics for fellowship training, the verbatim exercise supports achievement in at least three of the milestones. We present survey data over the past five years of our fellowship in support of the utility of this exercise and for consideration to include this exercise in a palliative medicine fellowship. We offer additional suggestions for further study of this formative tool. This article delineates the verbatim technique and its specific integration into our accredited ACGME Hospice and Palliative Medicine fellowship training program.

A restrictive and dichotomous question has become the primary approach in many goals of care discussions. Is the primary goal of care quantity of life through aggressive therapy or quality of life through comfort care and hospice? Even though many health care providers recognize that quality vs quantity of life (QvQ) is a false dichotomy, in practice QvQ underlies many goals of care discussions and can negatively impact patient care. This article offers strategies for assessing patients at the end of life, presenting a first-line conversation process that can support a range of treatment options as well as a diversity of dynamic patient values. Based on decades of experience in palliative care and a review of relevant literature, we recommend four practical questions to serve as values "vital signs," monitoring dynamic notions of quality of life and harmonizing patient values with treatment options.

Background: Persistent breathlessness is debilitating and increases in prevalence with advanced age and at end of life. This study aimed to evaluate any relationship between self-reported global impressions of change (GIC) in perceived health and breathlessness in older men.

Design: Cross-sectional study of 73-year-old Swedish men in the VAScular and Chronic Obstructive Lung disease study. A postal survey included items on perceived changes in health and breathlessness (GIC scales) and breathlessness (assessed using the modified Medical Research Council [mMRC] breathlessness scale, Dyspnea-12 and Multidimensional Dyspnea Scale) since age 65.

Results: Of 801 respondents, breathlessness (mMRC ≥2) was reported by 17.9%, worsening breathlessness by 29.1%, and worsening perceived health by 51.3%. Worsening breathlessness was strongly correlated with worsening perceived health (Pearson's correlation coefficient of 0.68 [p < 0.001] and Kendall's τ of 0.56 [p < 0.001]) and associated with more limited function (47.2% vs. 29.7%; p < 0.0001) and increased rates of anxiety/depression.

Conclusion: The strong correlation between perceived changes in health and persistent breathlessness helps delineate a more comprehensive picture of the challenges faced by older adults living with this disabling symptom.

Background: Management of docetaxel-induced edema is important as severe edema may lead to discontinuation of chemotherapy. Patients with stage IV breast cancer (BC) treated with docetaxel have shown lower limb edema; however, details of its developmental and healing processes are unknown, and thus management strategies have not been established. The aim of this study was to investigate the characteristics of the development and healing process of docetaxel-induced lower limb edema in stage IV BC patients.

Methods: This prospective observational study was conducted on patients with BC who were administered docetaxel between September 2020 and September 2021 at a National Hospital in Japan. Skin changes such as pitting test, circumference, along with ultrasound images and subjective symptom changes were evaluated. The progression of these changes was compared between patients with stage IV and non-stage IV disease.

Results: Five patients were enrolled in the study, of which two and one patients with stage IV and non-stage IV disease, respectively, developed lower limb edema. Early signs of lower limb edema were observed in ultrasound images, 15 cm below the peroneal head, before edema was confirmed by the pitting test and subjective symptoms. In patients with stage IV disease, edema worsened to Grade 3, and reduced four months after the end of drug administration.

Conclusion: For patients with stage IV disease, care should be initiated from the time the early signs are observed using ultrasound and continued for up to four months after the end of docetaxel administration.

Background: Palliative care is an essential element of universal health coverage. However, palliative care services, particularly pediatric palliative care (PPC) services, are still inadequately developed in many countries, not least members of the Gulf Cooperation Council (GCC) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). Advocating for palliative care services requires data-driven estimates of the number of patients needing these services.

Objective: To estimate the number of children living with life-threatening illnesses in the GCC countries requiring specialist and/or generalist palliative care service provision.

Method: Descriptive analysis of published cross-sectional epidemiological data. Subjects were from general and age-specific populations from individual GCC countries. The quantitative data on child population and mortality were collected from 2019 primary and secondary data sources. The need for PPC was estimated using mortality, incidence, and prevalence data from the Institute for Health Metrics and the Global Cancer Observatory.

Results: Our conservative analysis revealed that just under 22,000 children needed PPC in GCC countries in 2019, a minimum of 17.5 for every 10,000 children.

Discussion: There is a significant need for PPC services, suggesting that the medical needs of the pediatric population are currently not being fully met. Nationwide PPC services are essential to improve the quality of life of thousands of children in GCC countries by changing policies, professional education, and providing funding to palliative programs. To our best knowledge, this is the first study to highlight the clear and urgent need for the development of PPC services in the GCC countries.

Background: Most people in Japan wish to spend their final days at home, but the majority fail to do so; earlier studies indicated a more pronounced worsening of symptoms if treated at home.

Objectives: This study compared the prevalence of symptom worsening and explored associated factors between patients with advanced cancer receiving palliative care in palliative care units (PCUs) and at home.

Design: We conducted a secondary analysis of two multicenter, prospective cohort studies involving patients with advanced cancer receiving palliative care in PCUs or at home.

Setting/subjects: One study was conducted at 23 PCUs (January to December 2017) and the other on 45 palliative home care services (July to December 2017) in Japan.

Measurements: Symptom changes were categorized as stable, improved, or worse.

Results: Of the 2998 registered patients, 2877 were analyzed. Among them, 1890 patients received palliative care in PCUs, and 987 at home. Patients receiving palliative care at home were more likely to have worsening of pain (17.1% vs. 3.8%; p < 0.001) and drowsiness (32.6% vs. 22.2%; p < 0.001) than those in PCUs. By multivariate logistic regression analysis, palliative care at home was significantly associated with worsening of the Palliative Prognostic Index dyspnea subscale in the unadjusted model (odds ratio, 1.42 [95% confidence interval, 1.08-1.88]; p = 0.014) but not for any symptoms in the adjusted model.

Conclusions: After adjusting for patient background, the prevalence of symptom worsening was not different between patients with advanced cancer receiving palliative care at home and in PCUs.

Background: Due to a decision by the German Federal Constitutional Court of February 26, 2020, it is currently possible in Germany to avail of assisted suicide. The ruling has given rise to a controversial debate within the professional community as well as in society in general. Within this debate, little attention has been given to the role of nursing staff in assisted suicide. However, international studies show that nurses play an important role in assisted suicide.

Objective: The aim of this study is to assess the views and attitudes of nurses from different care settings in Germany toward assisted suicide.

Design: A qualitative research design was chosen to capture the subjective experience of nursing staff on suicide assistance. This was analyzed using the grounded theory method.

Methods: With the help of a semi-structured, narrative-generating interview guide, in which five case vignettes are integrated, 20 interviews were conducted with nursing professionals from different care settings throughout Germany.

Results: The analyzed phenomenon shows that nursing professionals need to understand the desire to die for themselves. The individual life situation of the respective patient is decisive. The action strategy based on being able to tolerate the wish to die determines how intensively they want to be involved before, during, and after assisted suicide. For nurses, however, it is undisputed that it is their professional role to accompany the patient in their "existence" and thus also in the context of assisted suicide.

Conclusion: In view of the future development of assisted suicide in Germany, it seems necessary to prepare nursing professionals for activities related to assisted suicide by means of a curricular offer. In addition, nursing professionals should be supported in forming their own attitude to the issue.

Background: The modern multimodal treatment of malignant tumors has increased disease-specific survival and decreased the burden of tumor-associated complications. The main focus of palliative surgery is not based primarily on quantitative success parameters of tumor response but is instead mainly on the question of quality of life.

Aim: The current study was conducted to analyze the clinical and oncological outcomes of palliative patients with soft tissue sarcoma.

Design: Of 309 patients with extra-abdominal high-grade soft tissue sarcoma treated between August 2012 and December 2014, our retrospective analysis revealed 33 palliative patients for this study. All patients were evaluated and managed by a multidisciplinary team with expertise and experience in sarcoma treatment. The survival analysis was made using the Kaplan-Meier method.

Results: The main sarcoma symptoms were pain (27.3%) and ulcerated tumors or shortly before ulceration (24.2%). Thirteen patients (39.4%) were operated on with negative margins, 15 (45.5%) with positive margins, 2 with tumor debulking (6.1%), and 3 patients (9.1%) were treated only with palliative hyperthermic isolated limb perfusion. Ten pedicle flaps were performed after sarcoma resection. The median operation time was 85 minutes (range, 37-216 minutes). The median hospitalization stay was 9.5 days (range, 3-27 days). No patients died during hospitalization. Twelve-month disease-free survival was 48.5% (95% confidence interval: 45.4-51.6).

Conclusions: Palliative surgery of metastatic or advanced soft tissue sarcoma can improve the wound care and quality of life. Closed noninfected wounds enable further treatment options, such as chemotherapy, immunotherapy, and radiotherapy. This surgery should be considered during the discussion on interdisciplinary tumor boards.

Background: Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications.

Objective: The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams.

Methods: Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis.

Results: Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors.

Conclusion: Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.