Annals of palliative medicine最新文献

Hospice use among Hispanic Medicare beneficiaries has declined in the last few years, and Hispanic caregivers have reported insufficient support around the emotional and spiritual aspects of care. Understanding the home hospice experience of Puerto Rican (PR) caregivers can yield insight into ways to improve hospice participation and quality of care for the Hispanic population. This exploratory study utilizes qualitative methods to identify PR caregivers' experience in the setting of home hospice care. Data from interviews with eight (n=8) bereaved PR caregivers of patients who received home hospice care were qualitatively analyzed. Participants were mostly well-educated (n=6/8) female caregivers caring for their parent (n=7/8) with mean age of 57 [standard deviation (SD) =13] years. Emerging domains from the study included (I) symptom management; (II) cultural and religious values; and (III) interaction with hospice providers. Caregivers found managing patients' loss of appetite, pain, anxiety, and confusion to be challenging. They identified family-centered values and religious support as culturally important, which manifested as the need for frequent communication from hospice providers and increased support and education at the end-of-life. Culturally tailored interventions that focus on managing symptoms, tailoring care to support family-centered values, integrating religious officials representative of the patient's beliefs into the hospice team, and communicating effectively with providers may reduce the burden experienced by PR caregivers in home hospice and improve outcomes for patients and caregivers. Additional research will aid in the development of evidence-based intervention and policies urging healthcare providers to offer culturally appropriate hospice care and resources to this population.

Background: Hospital-based specialized palliative care teams (HSPC) are important for symptom management and ethics support, especially during complex decision-making, but the needs of patients with noncancer diseases and their families from the HSPC are unclear. This study aimed to (I) compare the prevalence of symptom between patients with and without cancer and explore changes in symptom intensity after HSPC consultation in patients with noncancer; (II) determine factors related to ethics support; and (III) compare the percentage of request contents from patients and their families when a certified nurse specialist in gerontological nursing (geriatric care nurse below) is present in the HSPC to that when a certified nurse specialist in palliative care (palliative care nurse below) is present in the HSPC.

Methods: We utilized a retrospective cohort study to analyze 761 patients (360 with noncancer and 401 with cancer) referred to our HSPC at the National Center for Geriatrics and Gerontology using 10-year data (since 2011) available in an electronic medical record database. (I) Symptom scores of the Support Team Assessment Schedule were compared between noncancer and cancer groups and between initial and 1-week assessments for noncancer patients. (II) Ethics support was compared between noncancer (including dementia) and cancer. The presence or absence of ethics support requests, which was set as the objective variable, was examined using logistic regression analysis. (III) The percentage of request contents selected from nine items defaulted on the electronic medical record when a geriatric care nurse was present in our HSPC were compared to those when a palliative care nurse was present in our HSPC.

Results: Compared to those with cancer, patients with noncancer suffered more from dyspnea and sputum accumulation. More than 10% of patients with noncancer had suffered from pain, dyspnea, sputum accumulation, and anorexia that required treatment, with symptom scores showing improvement after 1 week of HSPC involvement, except for the sputum accumulation. Moreover, for anorexia, symptom scores improved, but >10% of these patients continued to suffer. Patients with noncancer diseases, including dementia, received ethics support than those with cancer without dementia. More requests for ethics support were received when a geriatric care nurse was in the HSPC than when a palliative care nurse was in the HSPC. Logistic regression analysis revealed that requests for ethics support were more frequent from patients or families with impaired decision-making capacity or when the patient lacked an advocate.

Conclusions: The needs of patients with noncancer diseases and families from the HSPC in Japan included (I) symptom management for intractable conditions, such as sputum accumulation; (II) ethics support for patients with noncancer diseases, including dementia, with

An increasing number of patients irradiated for metastatic epidural spinal cord compression (MESCC) experience an in-field recurrence and require a second course of radiotherapy. Reirradiation can be performed with conventional radiotherapy or highly-conformal techniques such as intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), and stereotactic body radiation therapy (SBRT). When using conventional radiotherapy, a cumulative biologically effective dose (BED) ≤120 calculated with an α/β value of 2 Gy (Gy2) was not associated with radiation myelopathy in a retrospective study of 124 patients and is considered safe. In that study, conventional reirradiation led to improvements of motor deficits in 36% of patients and stopped further symptomatic progression in another 50% (overall response 86%). In four other studies, overall response rates were 82-89%. In addition to the cumulative BED or equivalent dose in 2 Gy fractions (EQD2), the interval between both radiotherapy courses <6 months and a BED per course ≥102 Gy2 (corresponding to an EQD2 ≥51 Gy2) were identified as risk factors for radiation myelopathy. Without these risk factors, a BED >120 Gy2 may be possible. Scoring tools have been developed that can assist physicians in estimating the risk of radiation myelopathy and selecting the appropriate dose-fractionation regimen of re-treatment. Reirradiation of MESCC may also be performed with highly-conformal radiotherapy. With IMRT or VMAT, rates of pain relief and improvement of neurologic symptoms of 60-93.5% and 42-73%, respectively, were achieved. One-year local control rates ranged between 55% and 88%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0% and 0-9.3%, respectively. With SBRT, rates of pain relief were 65-86%. Two studies reported improvements in neurologic symptoms of 0% and 82%, respectively. One-year local control rates were 74-83%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0-4.5% and 4.5-13.8%, respectively. For SBRT, a cumulative maximum EQD2 to thecal sac ≤70 Gy2, a maximum EQD2 of SBRT ≤25 Gy2, a ratio ≤0.5 of thecal sac maximum EQD2 of SBRT to maximum cumulative EQD2, and an interval between both courses ≥5 months were associated with a lower risk of myelopathy. Additional prospective trials are required to better define the options of reirradiation of MESCC.

Background and objective: The prevalence of chronic non-cancer pain (CNCP) in older adults is high. Opioids carry significant risk for harm in older adults. Yet, many older adults are established on long-term opioid therapy for the treatment of CNCP despite limited documented efficacy. Many of the non-opioid options to treat pain present challenges in this population. Since challenges with tapering patients off of opioids exist, older adults may remain established on long-term opioid therapy for CNCP. While opioid use is less scrutinized for older adults receiving palliative care, significant safety concerns exist. Therefore, efforts to mitigate risks for older adults receiving long-term opioids for CNCP and for palliative care are essential. Pharmacists as members of the interprofessional team are equipped to improve safety among older adults on chronic opioid therapy. Among patients receiving palliative care, collaboration with palliative care specialists is also key. The purpose of this narrative review is to describe risk mitigation strategies for opioid use among older adults with CNCP and those receiving palliative care.

Methods: Data were identified by searching PubMed (January 1, 1990 to February 21, 2024) using the following search terms: older adults, opioids, chronic pain, palliative care, and pharmacist. The search was repeated using terms geriatric, elderly, opiates, narcotics, and controlled substances. Non-English articles and observational studies with fewer than 100 patients were excluded. Major North American and European guidelines were reviewed. Additional literature was obtained through review of relevant references of identified articles.

Key content and findings: A variety of risk mitigation strategies to improve safety for older adults using opioids exist. They include risk assessment, tapering opioids, reducing high-risk concomitant medications, utilizing non-opioid therapies, screening for and treatment of opioid use disorder (OUD), toxicology testing, co-prescribing naloxone, utilizing controlled substance agreements, reviewing prescription drug monitoring program data, prescriber and patient education, and collaboration with pharmacists and palliative care specialists.

Conclusions: There are many opioid risk mitigation strategies for older adults. Collaboration with pharmacists and palliative care specialists can be an effective means for implementing strategies to optimize opioid safety for older adults with CNCP and those receiving palliative care.

Advanced kidney disease is a progressive life-limiting illness associated with high symptom burden, disability, and highly intensive care near the end of life. There is growing interest in integrating palliative care principles into the care of patients with advanced kidney disease to improve care and outcomes for these patients. The United States (US) Department of Veterans Affairs (VA) has been a leader in advancing palliative care initiatives across its health system and whose experience and approach may be instructive to other health systems seeking to develop kidney palliative care (KPC) services. Herein, we review current KPC programs in the VA and highlight the different models of care that programs have been adopted and how key components of goals of care conversations and advance care planning, symptom management, multidisciplinary care, patient selection, and quality improvement have been implemented across programs. VA KPC programs have adopted "parallel", "merged", and "embedded" models of KPC that reflect the different configurations of partnerships between nephrology and palliative care providers to deliver KPC. A primary service of VA KPC programs is providing goals of care conversations and advance care planning to referred patients and systematically documenting the outcomes of these discussions in standardized note templates in the electronic medical record. Symptom management is delivered by KPC providers through regular shared or sequential visits with patients' nephrology providers and is guided by patient responses to validated symptom surveys. Programs are staffed by allied health professionals, such as chaplains, pharmacists, social workers, and dieticians, to provide whole-person care and regularly huddle with nephrology staff to reach a shared understanding of each patient's care needs and plan. KPC programs implement champions who select patients in greatest need of KPC using a combination of clinical events that trigger referral for KPC and validated mortality risk prediction scores that are automatically generated in each patient's medical record. KPC programs also routinely collect clinical, patient-reported, process, and care quality measures to assess its services. The experiences of the VA highlight novel approaches that strive to close the care gaps in meeting the KPC needs of patients with advanced kidney disease.

Background and objective: The majority of palliative care provision occurs in general practice, yet only 9% of palliative care clinical trials were conducted in this setting. Evidence from hospital and specialist settings is not readily transferable to general practice, as the population, context and care processes are vastly different. Conducting interventional palliative care research in general practice settings is subject to many challenges and barriers. This narrative review aims to describe the factors influencing the conduct of interventional research in general practice settings for patients with palliative care needs.

Methods: A narrative review was performed to identify factors affecting the conduct of palliative care interventional studies in general practice. A literature search of MEDLINE was conducted on 26 September 2023, and data were synthesised utilising a narrative approach.

Key content and findings: Sixteen articles were identified. Five thematic groupings were identified from the literature that affected the interventions: factors related to health care professionals (HCPs), patients and carers, general practices, health systems, and research design. HCPs and practices were focused on providing clinical care and struggled to incorporate research into their workload. Staff and patients often had negative perceptions in palliative care combined with limited research experience, often resulting in unwillingness to engage in interventions and gatekeeping. Engaging with general practice staff to design, participate and champion research were key facilitators of successful interventions.

Conclusions: Palliative care interventions in general practice are invariably complex and challenging, yet acutely needed to address the care needs of patients in the community setting. Working together with patients, carers and clinicians to design and implement interventions appropriate for general practice settings is fundamental to their success.

Indications for re-irradiation are increasing both for palliation and potentially curative attempts to achieve durable local control. This has been in part driven by the technological advances in the last decade including image-guided brachytherapy, volumetric-modulated arc therapy and stereotactic body radiotherapy. These enable high dose focal irradiation to be delivered to a limited target volume with minimal normal tissue re-irradiation. The European Society for Radiotherapy and Oncology (ESTRO) and the European Organisation for Research and Treatment of Cancer (EORTC) have collaboratively developed a comprehensive consensus on re-irradiation practices, aiming to standardise definitions, reporting, and clinical decision-making processes. The document introduces a universally applicable definition for re-irradiation, categorised into two primary types based on the presence of geometric overlap of irradiated volumes and concerns for cumulative dose toxicity. It also identifies "repeat organ irradiation" and "repeat irradiation" for cases without such overlap, emphasising the need to consider toxicity risks associated with cumulative doses. Additionally, the document presents detailed reporting guidelines for re-irradiation studies, specifying essential patient and tumour characteristics, treatment planning and delivery details, and follow-up protocols. These guidelines are designed to improve the quality and reproducibility of clinical research, thus fostering a more robust evidence base for future re-irradiation practices. The consensus underscores the necessity of interdisciplinary collaboration and shared decision-making, highlighting performance status, patient survival estimates, and response to initial radiotherapy as critical factors in determining eligibility for re-irradiation. It advocates for a patient-centric approach, with transparent communication about treatment intent and potential risks. Radiobiological considerations, including the application of the linear-quadratic model, are recommended for assessing cumulative doses and guiding re-irradiation strategies. By providing these comprehensive recommendations, the ESTRO-EORTC consensus aims to enhance the safety, efficacy, and quality of life for patients undergoing re-irradiation, while paving the way for future research and refinement of treatment protocols in the field of oncology.

Background: Dedicated palliative radiation oncology programs (PROPs) within radiation oncology (RO) practices have been shown to improve quality and decrease costs of radiation therapy (RT) in advanced cancer patients. Despite this, relatively few PROPs currently exist, highlighting an unmet need to understand characteristics of the few existing PROPs and the potential barriers and facilitators that exist in starting and maintaining a successful PROP. We sought to assess the attributes of existing PROPs, the facilitators and barriers to establishing these programs, and the resources needed to create and maintain a successful program.

Methods: A 15-item online survey was sent to 157 members of the Society of Palliative Radiation Oncology (SPRO) in July 2019.

Results: Of the 157 members, 48 (31%) responded. Most practiced in an academic center (71% at main center and 15% at satellite) and 75% were from a larger group practice (≥6 physicians). Most (89%) believed the development and growth of a dedicated PROPs was either important (50%) or most important (39%) to the field of RO. Only 36% of respondents had a PROP, 38% wanted to establish one, and 13% were currently developing one. Of those with PROPs (N=16), 75% perceived an increase in the number of referrals for palliative RT since starting the program. A majority had an ability to refer to an outside palliative care specialist (64%), an outpatient RO service (53%), and specialized clinical processes for managing palliative radiotherapy patients (53%), with 41% having an inpatient RO consult service. Resources considered most essential were access to specialist-level palliative care, advanced practice provider support, a radiation oncologist with an interest in palliative care, having an outpatient palliative RO clinic, an emphasis on administering short radiation courses, and opportunities for educational development. Of those with a PROP or those who have tried to start one, the greatest perceived barriers to initiating a PROP were committed resources (83%), blocked out clinical time (61%), challenges coordinating management of patients (61%), and support from leaders/colleagues (61%). Perceived barriers to sustaining a PROP were similar. For those without a PROP, the perceived most important resources for starting one included access to palliative care specialist by referral (83%), published guidelines with best practices (80%), educational materials for referring physicians and patients (80%), educational sessions for clinical staff (83%), and standardized clinical pathways (80%).

Conclusions: PROPs are not widespread, exist mainly within academic centers, are outpatient, have access to palliative care specialists by referral, and have specialized clinical processes for palliative radiation patients. Lack of committed resources was the single most important perceived barrier for initiating or maintaining