BMJ Supportive & Palliative Care最新文献

This is a shortened version of the personal reflections of the early developments of palliative care in Adelaide, South Australia delivered as the Rosalie Shaw Oration at the Australia and New Zealand Society of Palliative Medicine conference, Adelaide 6 September 2024: 30 years of palliative medicine: constructing, challenging and transforming.

Objectives: High physical activity levels have been associated with longer, healthier lifespans and improved quality of life among breast cancer survivors. The Japanese clinical guidelines for breast cancer survivors, similar to those in the USA, strongly recommend maintaining high physical activity levels. However, the extent of adherence to these guidelines among breast cancer survivors in Japan is unclear. This study aimed to assess adherence to guideline-recommended physical activities and identify associated factors.

Methods: Self-administered questionnaires were distributed to breast cancer survivors without recurrence or metastasis from 34 facilities across Japan, with approximately 30 survivors per facility, between March 2019 and August 2020. The questionnaire collected information on participants' backgrounds, physical activity levels (assessed using the Global Physical Activity Questionnaire) and potential factors influencing their physical activity. Logistic regression analysis was performed to identify the factors associated with meeting the guideline recommendations.

Results: In total, 791 patients (77.5%) were investigated, with 50.5% meeting the physical activity recommendations outlined in the guidelines. Factors associated with meeting the guideline recommendations included higher self-efficacy (OR 1.58, 95% CI 1.29 to 1.94), greater perceived social support (OR 1.54, 95% CI 1.26 to 1.89), lower annual household income (OR 1.58, 95% CI 1.07 to 2.33), relief from cancer-related symptoms through physical activity (OR 1.81, 95% CI 1.13 to 2.94) and urban location (OR 1.50, 95% CI 1.03 to 2.20).

Conclusions: Half of the breast cancer survivors in Japan did not meet the recommended physical activity levels, and several factors influencing adherence were identified.

Background: Discussions about euthanasia and physician-assisted suicide (EAS) involve various stakeholders, including patients, healthcare professionals and the general public. This review examines perspectives across different population subgroups to contribute to a broader understanding of EAS attitudes.

Methods: A systematic review of literature published prior to July 2023 with quantitative data about EAS views was undertaken. Details extracted from eligible papers included data year, geography, demographic features of population subgroups and levels of support for EAS under various circumstances. Proportions in support for EAS were calculated based on these factors. Meta-analyses were conducted to estimate changes in the proportion of support for euthanasia dependent on the presence or absence of pain or terminal illness in patients.

Results: The search identified 521 relevant studies. There were 1863 relevant survey questions with 1 945 945 individual responses, spanning years 1936 to 2023.478 studies explored whether EAS should be allowed, 134 examined clinician willingness to practise EAS and 78 investigated which persons might seek EAS. Clinician views were surveyed in 266 studies, public opinion in 139 and patient beliefs in 54.Support for EAS across studies and subpopulations varied widely. Mean support for EAS was lower in doctors than in the general public (25% compared with 55%). Support varied depending on access criteria to EAS with 54% support for patients in pain vs 36% for those without and 53% for terminally ill patients vs 29% for those without a terminal illness. Public support for EAS was lower in religious people, females, older people and African Americans.

Conclusions: Support for EAS varies widely across studies, with numerous demographic and situational factors associated with differing levels of support. This indicates a complex interplay of elements is involved in the formation of EAS beliefs. Understanding these factors is valuable for facilitating meaningful discussions among clinicians and the community and informing policy debates and decisions.

Background/objectives: Handgrip strength is a critical indicator of overall health, particularly in older adults, and is associated with frailty, sarcopenia and risk of adverse health outcomes. Precise and reliable measurement instruments are necessary to ensure accuracy in personalised diagnostic evaluations. This study aimed to assess the inter-instrument reliability and agreement between the Jamar Plus+ digital and Jamar hydraulic dynamometers in measuring handgrip strength.

Methods: A cross-sectional study was conducted to assess the handgrip strength of older individuals in the community aged more than 60, using the Jamar Plus+ digital and Jamar hydraulic dynamometers. The inter-instrument reliability and agreement between the devices were evaluated using Intraclass Correlation Coefficients (ICCs) and Bland-Altman analysis.

Results: A total of 109 participants with a mean age of 66±5.3 years were included in this study. The Jamar Plus+ digital dynamometer recorded significantly higher handgrip strength measurements (27.0±7.1 kg) compared with the Jamar hydraulic dynamometer (21.0±6.7 kg). The ICCs between the two devices ranged from 0.67 to 0.70, indicating moderate reliability. Bland-Altman analysis revealed a consistent overestimation of handgrip strength by the Jamar Plus+ digital dynamometer, with systematic biases of 4.8 kg in men and 6.26 kg in women compared with the Jamar hydraulic dynamometer.

Conclusion: The Jamar Plus+ digital dynamometer consistently overestimated handgrip strength compared with the Jamar hydraulic dynamometer, but both devices demonstrated moderate reliability. The Jamar Plus+ showed greater responsiveness to variations in strength. Selecting appropriate diagnostic tools is crucial for optimising individualised health assessments in older adults.

Introduction: Patients with ventilator-dependent motor neuron disease (MND) may request withdrawal of their assisted ventilation. Facilitating this process as a healthcare professional (HCP) can be emotionally and practically challenging. The Association for Palliative Medicine (APM) issued guidance to support HCPs and invited anonymised accounts of the withdrawal process to provide an update on the guidance.

Methods: HCPs submitted anonymised accounts via email. Quantitative data was analysed descriptively in Excel. Free-text comments were analysed thematically using an inductive, iterative approach.

Results: 68 HCPs submitted 95 accounts of ventilation withdrawal between 2015 and 2024. Most patients received medications pre-withdrawal (94%), primarily a combination of an opioid and midazolam, mostly subcutaneously. Younger patients tended to need higher doses to achieve adequate symptom management prior to withdrawal. Practices of weaning the ventilator varied significantly between respondents. The median time to death following withdrawal of ventilation was 30 min, with three-quarters of patients dying within 2 hours.

Conclusion: This is the largest data set to date regarding the withdrawal of assisted ventilation in MND. This updated analysis reaffirms that a personalised, titrated approach remains appropriate and effective. The revised APM Guidance 2025 incorporates new sections on recommendations for managing the ventilator.

Background: Ambulatory palliative care clinics are associated with improved outcomes in cancer patients, including short-term quality of life. However, their impact on individual patient-reported symptoms is not well understood.

Aim: We evaluated the impact of ambulatory palliative care on individual symptoms in adult cancer patients.

Design: Following a standard protocol (PROSPERO: CRD42022321909), investigators independently identified randomised and non-randomised intervention studies that assessed patient-reported symptom scores using validated symptom assessment scales longitudinally. Data were synthesised using random-effects meta-analyses.

Data sources: Database of PubMed, CINAHL, EMBASE, PsycINFO and Cochrane Central was searched from inception to September 2023 for eligible studies.

Results: 20 studies encompassing 4 prospective cohort studies, 1 randomised control trial and 15 retrospective studies were included. Most studies focused on cohorts with advanced cancers of mixed primary tumour type, were colocated within or linked to a tertiary cancer centre and assessed symptoms using the Edmonton Symptom Assessment Scale (ESAS). The meta-analyses confirmed evidence for improvement in pain (standardised mean difference (SMD) 0.31, 95% CI 0.18 to 0.44), anxiety (SMD 0.31, 95% CI 0.12 to 0.49), fatigue (SMD 0.31, 95% CI 0.10 to 0.51), insomnia (SMD 0.29, 95% CI 0.15 to 0.42), depression (SMD 0.25, 95% CI 0.09 to 0.40), drowsiness (SMD 0.23, 95% CI 0.11 to 0.34), well-being (SMD 0.28, 95% CI 0.12 to 0.45) and overall symptom burden (SMD 0.29, 95% CI 0.22 to 0.36). There was no evidence for improvement in nausea (SMD 0.19, 95% CI -0.02 to 0.40), dyspnoea (SMD 0.16, 95% CI 0.02 to 0.29) and appetite scores (SMD 0.14, 95% CI -0.00 to 0.29).

Conclusions: Ambulatory palliative care had positive effects on multiple common symptoms. The strength of this evidence however is low, largely due to the considerable heterogeneity among included studies. Further research could determine thresholds on symptom assessment scales to guide urgency of referral, timing of follow-up and optimal multidisciplinary staff involvement.

Purpose: This study aimed to assess the levels of physical activity (PA) and functional capacity of breast cancer patients before and after neoadjuvant chemotherapy.

Methods: The investigation comprises a prospective cohort study including women 18 years or older who underwent neoadjuvant chemotherapy for breast cancer at a single oncology centre between 4 April 2016 and 31 October 2018. Patients were evaluated in terms of self-reported PA levels and physical capacity using the following physical tests: handgrip strength, sitting and standing up in 30 s and stationary walking for 2 min. Variables were compared before and after neoadjuvant chemotherapy using the Wilcoxon test.

Results: A total of 440 women were analysed, 88.2% of whom presented at an advanced clinical stage. The mean age of the patients was 51.0 years (±11.0), 68.0% were non-white and 53.9% were not working at the time of diagnosis. Decreased PA levels and handgrip strength (p<0.002) were observed following chemotherapy, although no changes in aerobic capacity and lower limb resistance (LLR) were noted (p=0.595 and p=0.163, respectively).

Conclusion: Women with breast cancer exhibit decreased PA levels and handgrip strength following neoadjuvant chemotherapy, although no alterations in aerobic capacity and LLR were observed at the end of treatment.

Introduction: Fatigue and breathlessness are among the most distressing symptoms for palliative care patients and may be related to underlying anaemia. Red cell concentrate (RCC) transfusion is a common intervention, yet its efficacy in improving these symptoms in palliative populations remains unclear.

Methods: This retrospective chart review examined the impact of RCC transfusion on fatigue, breathlessness and functional status in 33 patients admitted to a hospice inpatient unit over 30 months. Symptom and functional scores were assessed pre-transfusion, and at 14 and 30 days post-transfusion, using the Palliative Care Outcomes Collaboration Symptom Assessment Scale, Australian Karnofsky Performance Status (AKPS) and Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) tools.

Results: Results showed that fatigue scores improved in 58% of patients, with sustained improvement at 30 days in 36%. A statistically significant reduction in fatigue was observed at 14 days post-transfusion (p=0.02). However, the impact on breathlessness was limited, with only 18% of patients reporting improvement, and no significant changes in mean breathlessness scores over time. Functional status, measured by AKPS and RUG-ADL, declined in 36% and 27% of patients, respectively, likely reflecting the progressive nature of terminal illness.

Conclusions: While RCC transfusion demonstrated potential for alleviating fatigue, particularly in the short term, its effects on breathlessness and functional status were limited. The high mortality rate (30% at 30 days) and small sample size highlight the challenges of research in this population. These findings support the role of RCC transfusion in managing fatigue in palliative care, though further prospective studies are warranted.

Objectives: Patients with haematological malignancies (HM) experience high-intensity medical care near the end of life (EOL), have low rates of hospice and palliative care (PC) use and are more likely to die in the hospital. We compared the quality indicators for EOL care in patients followed by a haematologist with or without PC.

Methods: This observational, retrospective study evaluated a cohort of 196 consecutive patients with HM. We used a mean composite score for the aggressiveness of EOL. The quality indicators evaluated were chemotherapy, place of death, transfusions and hospital use in the last month of life.

Results: Eighty patients were offered PC and 116 were not. The composite score for aggressive EOL care was significantly higher for patients not followed by PC (2.2 vs 0.5; p<0.0001). None of the PC group patients was intubated or admitted to intensive care; 91.2% of the patients followed by PC died at home or in hospice, while 81.9% of the other patients died in the hospital.

Conclusion: Many patients who died of HM received intensive treatment near EOL. Our data support the value of integrating PC into the HM routine practice and can be the basis for new studies.