Annals of palliative medicine最新文献

Background: The rising prevalence of serious illnesses has increased the demand for emergency department (ED) services. Patients with advanced chronic conditions frequently present to the ED with distressing symptoms. Although symptom prevalence has been well described in oncology populations, fewer studies have assessed non-cancer illnesses, particularly in the ED. This study aimed to compare symptom prevalence in patients with cancer and non-cancer illness awaiting hospitalization after ED admission and referred to the hospital palliative care (PC) team.

Methods: We conducted a prospective, observational, cohort study over 2 years [2023-2024] at a tertiary university hospital. Adults with serious illness referred from the ED to the hospital PC team were eligible if they had ≥1 symptom scoring ≥4 in a numeric rating scale (NRS) ranging from 0 to 10. Thirteen symptoms were evaluated, encompassing physical, psychological, and spiritual domains. Prevalence was analyzed descriptively and compared between cancer and non-cancer groups using Fisher's exact test.

Results: Among 542 patients screened, 416 met eligibility criteria: 141 (34%) with cancer and 275 (66%) with non-cancer illness. Nearly all patients reported at least one symptom ≥4. Compared to non-cancer patients, those with cancer more often experienced pain (49% vs. 31%, P<0.001), fatigue (84% vs. 75%, P=0.02), appetite loss (54% vs. 32%, P<0.001), nausea (22% vs. 13%, P=0.02), vomiting (16% vs. 6%, P=0.004), and diarrhea (11% vs. 4%, P=0.01). In contrast, dyspnea was significantly higher in non-cancer illness (62% vs. 35%, P<0.001). Several symptoms were common in both groups without significant differences.

Conclusions: This study shows that seriously ill patients presenting to the ED experience substantial symptom burden, but with distinct profiles between cancer and non-cancer conditions. In this sample, pain, fatigue, and gastrointestinal symptoms predominate in cancer, while dyspnea characterizes non-cancer illness. These findings underscore the need for systematic symptom screening and early PC referral in the ED to ensure equitable, timely, and effective symptom relief across all serious illnesses.

Background: It is common for patients with cancer to present with delirium during cancer treatment due to various causes, such as infection, electrolyte abnormalities, medications, and brain metastasis. Furthermore, delirium may also occur when a patient with cancer develops Trousseau syndrome. Delirium due to Trousseau syndrome in a cancer patient with a history of repeated delirium might be mistaken for previous episodes, which could lead to overlooking a stroke.

Case description: A male aged 90 years with gallbladder cancer was admitted to the hospital. During hospitalization, he experienced recurrent episodes of cholangitis and fever, accompanied by delirium. His inflammatory response decreased, and his fever resolved following antibiotic treatment. After recovery, he experienced a loss of appetite, and olanzapine (2.5 mg/day) was started on Day 17 of hospitalization. However, early on Day 21, he suddenly became restless, moaned loudly, and exhibited signs of delirium. Initially, delirium due to olanzapine or reinfection was suspected. However, a new stroke was suspected because of speech impairment as well as the sudden onset of delirium. Head magnetic resonance imaging revealed a fresh stroke in the right basal ganglia, which was identified as the cause of the delirium.

Conclusions: Patients with cancer are more prone to developing stroke due to the hypercoagulable state associated with malignancy. Even in the absence of obvious neurological signs, such as hemiplegia, the possibility of Trousseau syndrome needs to be considered when a patient presents with atypical or sudden-onset delirium.

Background: Emergency medicine (EM) and internal medicine (IM) physicians care for patients in settings where prompt recognition of and effective communication about acute decompensation and the potential for imminent death is crucial to providing goal-concordant care. Competence in these tasks requires dedicated training and facilitated practice in serious illness communication (SIC). Existing simulation-based SIC curricula typically utilize cases in which the diagnosis and prognosis are already established in a medically stable patient, representing a missed opportunity for learners. To fill this gap, the authors aimed to explore IM and EM resident perceptions of a novel, entirely virtual SIC curriculum, Managing Acute Decompensation in Life-limiting Illness (MADLI), that required participants to assess and manage a clinically decompensating seriously ill patient while simultaneously incorporating newly learned SIC skills.

Methods: Sixteen participants were recruited from the EM and IM residency programs at a large, tertiary, academic medical center. Using a "flipped classroom" approach, residents asynchronously viewed a 20-minute didactic video introducing evidence-based communication frameworks. In small peer groups led by a trained faculty facilitator, they then participated in a 60-minute simulated clinical encounter involving an acutely decompensating patient and their surrogate decision maker, played by an SIC-trained actor. Lastly, residents participated in a 30- to 60-minute semi-structured group interview. Qualitative thematic analysis was performed to identify overarching themes that resulted from the interview data.

Results: Qualitative analysis of group interview transcripts yielded 3 major themes that reflect the trainee experience with the MADLI curriculum: (I) simulation unmasked moral challenges; (II) simulation facilitated safe practice and identification of knowledge gaps for SIC skills; and (III) task switching and case realism were virtual SIC curricular elements that promoted learner engagement and effective learning. Additionally, integrating medical management and SIC tasks was perceived as novel, challenging, and realistic. Residents who completed the MADLI curriculum viewed it as an effective modality to teach SIC.

Conclusions: Simulation-based curricula for EM and IM residents that combine medical management, prognostication, and complex SIC into a single virtual, simulated patient encounter can address critical gaps in resident education related to the management of seriously ill patients at high risk of imminent death. Incorporating a trained actor and task-switching enhanced realism and learner engagement, highlighting the value of this model as a feasible approach to advancing IM and EM resident SIC skills.

Background: Pain is prevalent among cancer patients and impairs quality of life. Telemedicine, including electronic patient-reported outcomes (ePROs), is a promising tool for remote pain management. The objective of this review is to critically analyze studies on the use of telecommunication technologies for pain management in patients with advanced cancer receiving palliative care.

Methods: A systematic search was conducted in PubMed, the Cochrane Library, CINAHL, MEDLINE, Web of Science, and Scopus for literature published up to December 31, 2024. The eligibility criteria were defined based on the PICO framework: P (Population): adult patients with advanced cancer-related pain; I (Intervention): telecommunication technology interventions delivered by healthcare professionals to reduce cancer-related pain; C (Comparison): usual care; O (Outcome): change in pain levels.

Results: Ten studies met the predetermined eligibility criteria. Among these, eight studies demonstrated a statistically significant between-group effect of the interventions on pain reduction, while two of four studies reported time-series effects of telemedicine, although these effects were not significantly different from those observed in the control group. In the latter group, symptom self-reporting via an ePRO system was utilized, and the collected information was incorporated into pain management strategies. Among the eight studies demonstrating the effectiveness of ePRO-based pain management, five involved patients reporting their pain status to healthcare providers and receiving advice and education on pain management. Three of these studies incorporated real-time responses from healthcare providers. The duration of the interventions varied across studies: one study lasted 1 week, two studies lasted 4 weeks, one study lasted 8 weeks, and one study extended to 6 months. The frequency of intervention also varied: three studies employed daily interventions, one used twice-weekly interventions, and one study also used twice-weekly interventions. Interventions were delivered by healthcare professionals such as pharmacists, nurses, physical therapists, and researchers.

Conclusions: A wide range of intervention durations, healthcare professionals, and methods utilizing telecommunication technologies for cancer pain management were identified. The use of ePRO systems by healthcare providers for patients with advanced cancer shows potential; however, a consensus on the optimal approach remains lacking, highlighting the need for further validation.