Annals of palliative medicine最新文献

Background: Agitated delirium frequently poses management challenges in palliative care. Interventions are needed to manage delirium yet allow meaningful end-of-life communication. Dexmedetomidine can provide wakeful sedation and may fill this therapeutic need. Our objectives were to study the safety and efficacy of using dexmedetomidine in inpatients with agitated delirium.

Methods: In a prospective study, ten adult patients received a dexmedetomidine infusion for agitated delirium in the Bruyère Health inpatient Palliative Care Unit. Following the introduction of an approved subcutaneous dexmedetomidine protocol, doses (range, 0.2-0.7 mcg/kg/h) were titrated to achieve wakeful sedation, targeting a Richmond Agitation-Sedation Scale Palliative version (RASS-PAL) level of -1 to +1.

Results: Seventy percent (7/10), 50% (4/8), and 83% (5/6) of patients achieved the RASS-PAL target sedation level at least once per day on Days 1, 2, and 3 of dexmedetomidine infusion, respectively. Those who did not consistently achieve target sedation typically died in less than 3 days. Most patients (n=7) received a maximum dexmedetomidine dose of 0.4-0.5 mcg/kg/h. Dexmedetomidine was discontinued prior to death in five cases due to perceived ineffectiveness (n=1), family requesting deeper sedation (n=1), asymptomatic hypotension (n=2), or bradycardia (n=1). In patients with transient hypotension or bradycardia, death occurred 19 h to 18 days following dexmedetomidine discontinuation.

Conclusions: Subcutaneous dexmedetomidine infusion may be a safe and effective way of providing wakeful sedation for patients with agitated delirium in palliative care. However, prospective, controlled studies with standardized approaches to co-sedative and analgesia management are needed to better determine efficacy, adverse effects, and inform patient selection.

Background: Palliative care focuses on improving the quality of life and comfort of patients in the last stages of their disease by providing relief for pain and other distressing symptoms, and it integrates physical, psychological, and spiritual aspects. The main objective of this study is to assess the impact of palliative care in the administration of active treatment during the last 3 weeks of life of patients with advanced non-small cell lung cancer (NSCLC) and its impact on survival after the last treatment cycle.

Methods: A retrospective study was conducted across two centers, analyzing data from both sites to evaluate outcomes and trends in patient care. It includes 118 deceased patients who had been diagnosed with NSCLC between 1/1/2019 and 30/4/2024. The patients had received at least one cycle of active treatment with chemotherapy, immunotherapy, or both. Patients with druggable mutations in their first line were excluded.

Results: Overall survival (OS) after the last cycle was 56 days in the patients treated by the palliative care unit [95% confidence interval (CI): 41.6-70.4] vs. 27 days for those who were not treated by the unit (95% CI: 19.4-34.5) (Plog-rank<0.001); hazard ratio (HR) 3.23 (95% CI: 2.01-5.13) (P<0.001). In patients ≥75 years old, survival after the last cycle was 47 days (95% CI: 33.9-60.1) vs. 34 days (95% CI: 24.9-43.1) for those <75 years old (Plog-rank<0.001). In patients with ECOG 2, the survival after the last cycle was 56 days for those assessed by the palliative care unit (95% CI: 42.9-69.1) vs. 23 days (95% CI: 19.5-26.5) for those who had not been assessed (Plog-rank<0.001). In patients who had been assessed by the palliative care unit, the odds ratio (OR) to receive treatment in the last 3 weeks of life was 0.20 (95% CI: 0.07-0.57) (P=0.002). In patients under 75 years old, the OR was 2.83 (95% CI: 1.03-7.72) (P=0.042).

Conclusions: The assessment by multidisciplinary teams that integrate palliative care doctors has a significant impact on the decision to withhold active treatment over the last 3 weeks of life in patients with advanced NSCLC. The greatest benefit is observed in patients with performance status measured by Eastern Cooperative Oncology Group (ECOG) ≥2.

Advanced lung disease, including chronic obstructive pulmonary disease (COPD) and various types of interstitial lung disease (ILD), are common disabling respiratory conditions with increasing prevalence in older adults. In this chapter, we provide an overview of COPD and ILD along with a summary of palliative care issues relevant to these populations. While the diseases tend to be gradually progressive, the time course and prognostication is highly variable with long periods of stability and occasional severe exacerbations. The symptom burden in advanced lung disease is high, with significant dyspnea, including physiologic dyspnea from hypoxia and hypercarbia as well as psychological, spiritual, interpersonal aspects of dyspnea which together are described as "total dyspnea". Functional status is often significantly impaired, and co-morbid depression and anxiety are common. Palliative care is important for symptom management as well as advance care planning (ACP) and end-of-life (EOL) preparations. Non-pharmacologic interventions should be the first line for approaching dyspnea, and pulmonary rehabilitation is an important avenue for improving functional status and providing palliative care education. Opioids are available for pharmacologic management of refractory dyspnea. Early palliative care is important for people with COPD and ILD, as they learn to navigate the burdens of chronic illness. Further research and education are needed to enhance palliative care efforts in this complex population.

Background: Persons diagnosed with progressive neurological disease who experience breathing difficulties and impaired cough function, are a vulnerable group. Some are in the late end-of-life stage, and providing the right kind of support is a challenge. There is a need to address the broader experiences of living with a progressive neurological disease including breathing difficulties and impaired cough function. Therefore, the aim was to explore persons' experiences of living with progressive neurological disease and breathing difficulties.

Methods: We used qualitative content analysis, drawing on 15 interviews with 10 persons with progressive neurological disease.

Results: Living with progressive neurological disease and breathing difficulties can be understood as a reconciliation with a difficult life, a powerlessness in the struggle against deterioration and a fluctuation between feelings of trust and mistrust. An acceptance of the severity was described and a strive to make the best of life. The ongoing struggle against deterioration brought feelings of uncertainty, fear, and powerlessness, impacting the entire life. Feeling safe, supported, and receiving symptom-relief care highlighted the importance of being listened to, feeling goodwill and caring presence of others. Feeling badly treated and, not respected as a whole and competent person, were expressed as being devastating and a sense of being abandoned by health care.

Conclusions: Our study emphasizes the importance of providing palliative person-centered care for this group. This implies a holistic, dignity-preserving, empathetic and compassionate care including symptom relief early in the illness trajectory.

Background: In the majority of cultures, death is accompanied by a series of rituals that assist the bereaved in coping with this significant transition. However, there is a paucity of empirical literature on the organisation of such rituals. The objective of this multidisciplinary study was to collate an inventory of rituals and ritual elements. This data will be employed to develop a repertoire of rituals. The research was conducted in Germany. The participants in the second phase were primarily hospital chaplains. Consequently, the data collected primarily related to rituals anchored in a Christian context.

Methods: We initiated a multidisciplinary research project (palliative medicine, cultural anthropology, theology) on rituals in end-of-life care. The study employed a mixed-methods approach, comprising three phases, and was conducted in Germany. In this paper, we present the results of a survey on professionals conducted using an online questionnaire. The aim was to explore the general understanding, demands, practices and further suggestions from clinical practice (phase 2). The questionnaire consisted of both open and closed questions. It should be noted that the survey did not enquire about the respondents' religious affiliation. The responses to the closed questions were analysed statistically, while the open-ended responses were analysed qualitatively.

Results: A total of 299 questionnaires were completed, primarily by chaplains, nurses, and doctors. The respondents described a wide range of rituals, and across all professions, there was a high to medium perceived need for the use of rituals for patients nearing the end of their lives and their relatives. Rituals at the end of life were found to be highly relevant in terms of providing support and structure, expressing emotions, and experiencing community. The spectrum of rituals extends from established and extensive religious rituals to smaller everyday actions that are elevated to the status of rituals.

Conclusions: As religious traditions are no longer practised by an increasing number of people; it may be reasonable to develop new rituals for the dying phase that can be adapted and used by palliative care staff to suit the respective context. These rituals could make a valuable contribution to the care of the dying, their relatives and the professional team.

Radiofrequency ablation (RFA) is a neuromodulation technique that uses electrocautery to damage nerves with thermal energy and interrupt nociception and has primarily been used to treat patients with chronic back pain. While the use of RFA to modulate neuronal innervation of cervical and lumbar facet joints is well studied, research on the applications of RFA to target the thoracic spine is limited despite these facet joints accounting for pain in over 25% of patients with chronic mid-back and upper-back pain. The purpose of this paper is thus to describe RFA and its utilization in the thoracic spine for chronic back pain. A review of the literature on PubMed was conducted to identify primary evidence for RFA with a focus on only the thoracic spine. Nine papers were identified and reviewed in this article. Primary literature published on RFA-naive patients with thoracic facet joint pain has provided evidence in support of RFA for short-term and long-term pain relief in this spinal region. However, all but two of these studies utilized a cohort study design. Future studies with larger patient cohorts or that utilize a randomized control trial study design are crucial to better establish the effectiveness and long-term utility of this neuromodulation technique.