BMJ Supportive & Palliative Care最新文献

Objectives: Men with castrate-resistant prostate cancer (CRPC) suffer from symptoms related to both their disease and its treatment with marked variation between individuals with respect to symptom expression. This study aimed to determine whether genetic variation in cytokine expression is associated with symptom severity.

Methods: An exploratory prospective, longitudinal consecutive patient cohort study was undertaken across two Queensland sites. Patient characteristics including tumour burden and current treatment were collected at baseline. Symptom severity was assessed 3-4 weekly for up to 6 assessments, with blood taken for genetic analysis once only during the study. Cytokine gene variants of each participant were assessed using a panel of single nucleotide polymorphisms (SNPs) most described in the literature.

Results: Of the 66 participants, 27/66 (41%) had a low, and 39/66 (59%) a high tumour burden. Symptom severity was not related to tumour burden or patient characteristics. Of the 142 SNPs analysed from 62 participants, 15 SNPs from 7 genes were significantly associated with symptom severity. After Benjamini-Hochberg adjustment, SNPs rs2069772 from Interleukin-2 (IL2) and rs230494 from Nuclear Factor kappa-light-chain-enhancer of activated B cells (NFKb) remained significant.

Conclusion: Although multiple factors can influence symptom severity, genetic variation may play a part. The early identification of men likely to develop severe symptoms during the course of their prostate cancer could theoretically enable symptoms to be managed more aggressively from an early stage. These preliminary findings need to be replicated in a larger cohort of men with CRPC.

Objectives: To evaluate the incidence, pattern and risk factors of early cardiotoxicity and to assess the impact of undernutrition in children with Wilms tumour (WT) and hepatoblastoma receiving anthracycline-based therapy.

Methods: In this retrospective cohort study, 137 children treated between 2017 and 2022 were analysed. Cardiac function was monitored by serial echocardiography, and nutritional status was assessed using WHO and Pediatric Hematology-Oncology Association of Central America (AHOPCA) criteria. Multivariable logistic regression was performed to identify factors associated with early cardiac dysfunction.

Results: The incidence of early cardiotoxicity was 11.7%. Majority of patients who developed cardiotoxicity were asymptomatic. Undernutrition, assessed by WHO and AHOPCA criteria, was highly prevalent and significantly associated with cardiac dysfunction. Most affected patients showed recovery with medical management.

Conclusions: Undernourished children receiving anthracycline therapy for WT and hepatoblastoma are at increased risk of early cardiotoxicity. Routine nutritional assessment, early intervention and close cardiac monitoring may help mitigate acute cardiac toxicity in this vulnerable population.

Background: Rituals are a universal phenomenon in human culture, which act to support and process transitions and challenges. The objective of this integrative review was to synthesise the evidence for the types of rituals, whether traditional, religious or idiosyncratic, that are used by people witnessing or experiencing the dying process, as well as the specific elements and impacts of such activities.

Methods: This review used methodology proposed by Whittemore and Knafl⁹ and searched the following databases: Web of Science, Medline, PubMed, CINAHL and EMBASE. Articles were limited to qualitative and quantitative studies in English with keywords in the title or abstract and no limits on year of publication. Of the 482 studies identified, 34 were included and categorised as rituals conducted for patients, staff or patients and staff together. Data analysis involved deductive content analysis and a narrative approach to summarise the synthesised results.

Results: Two distinct ritual patterns that differed in purpose and impacts were identified: rituals within coherent religious or cultural frameworks and personally-derived idiosyncratic rituals. Traditional religious and cultural rituals supported passage from life to death and affirmed identity and belonging, while idiosyncratic rituals affirmed individuality and provided psychosocial and physiological support.

Conclusion: Rituals continue to be defined ambiguously and evolve organically to signify the significance of death. Rituals support a 'good death' as unification with a divine force or through honouring values of individualism, humanism and existentialism. The level of impact of rituals depends on conscious use of collectively understood symbolism for context and participants.

Objectives: To investigate why residents of residential aged care homes (RACH) are transferred to hospital for end-of-life care (EoLC).

Methods: We audited electronic health records at one tertiary referral centre hospital (New South Wales, Australia) from 1 June 2021 to 30 May 2023.

Results: Over a 2 year period, there were 2535 presentations to the emergency department (ED) from RACH, of which 45% were transferred back to RACH, 9% died in ED and 46% were admitted to hospital. Only 17% of those admitted were referred to palliative care, with an average delay of 3 days. The most common reasons for admission were falls, shortness of breath and sepsis. Most patients were in extremis at the time of referral, with an average time to death of 3 days; this was the most common barrier to returning patients to RACH (48%). In other cases (30%), the desired place of care was hospital or there was an urgent reason for admission, for example, fracture requiring surgery.

Conclusions: Once RACH patients are admitted to hospital for EoLC, there is little time to influence the trajectory of care. Future efforts should focus on supporting care in RACH and providing EoLC in situ.

Objectives: On rare occasions, hiccups can cause morbidity, such as sleep deprivation, aspiration and even death. At times, palliative invasive procedures are considered. This study tested the hypothesis that invasive procedures can provide hiccup palliation with an acceptable safety profile.

Methods: Multi-site electronic medical data were used to assess adult patients who underwent an invasive procedure for hiccups between January 1995 and January 2022. Hiccup palliation was defined as documented improvement in severity or frequency of this sign/symptom after the procedure.

Results: A total of 69 patients underwent one or more invasive procedures for hiccups (144 total procedures). Fifty-nine patients (86%) were men. The most frequent initial procedure was a phrenic nerve block (n=10) followed by oesophageal dilation (n=9). Only 31 patients (45%) manifested hiccup palliation after their first procedure. Nearly half, or 32 patients (46%), underwent more than one procedure (2 underwent nine procedures). Of these subsequent procedures, 35 resulted in palliation. Five adverse events arose from 144 procedures: post-esophagectomy atrial fibrillation, haematoma after cardiac device removal, vocal cord immobility after craniotomy, vocal cord immobility after vagal nerve manipulation, and a cerebral spinal leak after vagal nerve decompression.

Conclusions: Invasive procedures can palliate hiccups with an acceptable safety profile. However, these procedures appear to palliate hiccups in only about half of patients and sometimes do so only transiently.

Objectives: This study aimed to evaluate the prognostic significance of the corneal reflex in predicting death within 24 hours among terminally ill patients with cancer.

Methods: This prospective observational study was conducted with patients with advanced cancer admitted to the hospice centre of Gyeongsang National University Hospital who were in the phase of impending death. Corneal reflex and other end-of-life signs were assessed three times daily by trained nurses using standardised criteria. Mixed-effects logistic regression was used to identify predictors of death within 24 hours, and diagnostic performance was examined for 24-96 hours.

Results: A total of 665 observations was analysed. Absence of corneal reflex was strongly associated with death within 24 hours (OR 5.48, p<0.001), with a 24-hour mortality rate of 70.7%. It showed high specificity (85.0%) and positive predictive value (70.7%). Even among patients with a Richmond Agitation-Sedation Scale score of -4 or -5, absence of the corneal reflex remained a significant predictor of 24-hour mortality (71.2% vs 37.1%, p<0.001). Other significant predictors included peripheral cyanosis, oxygen desaturation and low blood pressure.

Conclusions: Absence of corneal reflex is a specific and clinically useful sign of imminent death within 24 hours in terminally ill patients with cancer, supporting its application in end-of-life prognostication and decision-making.

Background: Intraoperative deaths, though statistically rare, may evoke varied emotions among operating room (OR) staff that remain underrecognized and inadequately addressed.

Aim: To synthesise the qualitative evidence regarding experiences of OR staff following patient death in the OR. A secondary aim is to unpack strategies to support OR staff following an intraoperative death experience.

Design: Narrative review of qualitative studies.

Data sources: Peer-reviewed databases (PubMed, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Review Library) and grey literature sources (such as thesis databases) were extensively searched for peer-reviewed primary studies and non-peer-reviewed literature respectively reporting on intraoperative deaths or deaths occurring in the OR.

Results: Six studies were retained. The synthesis revealed that unexpected OR deaths or those deaths perceived as sudden or preventable evoked more severe and enduring psychological repercussions, marked by guilt, hypervigilance, emotional and moral distress.In contrast, anticipated fatalities, particularly in patients with advanced illness, evoked less intense emotions but did not eliminate emotional tolls. The findings revealed divergent coping mechanisms among OR professionals: surgeons often engaged in meaning-making or employed emotion-focused and problem-focused strategies to process loss. In contrast, anaesthetists described emotional desensitisation over time. Nurses, meanwhile, navigated a pervasive culture of silence.

Conclusion: The emotional toll captured underscores urgent needs for interventions, such as team-based debriefing support, alongside systemic reforms to normalise vulnerability and integrate emotional stewardship into institutional policies.Addressing this is not only ethically imperative but critical to sustaining a resilient workforceand ensuring patient safety in an era of escalating surgical demand.

Objectives: Families of patients with cancer often experience significant psychological distress, yet family care remains insufficiently addressed in current healthcare systems. This study aimed to investigate the acceptability of alternative care delivery methods among families of patients with cancer to seek insights into feasible and sustainable approaches to family-inclusive cancer care.

Methods: A cross-sectional survey of bereaved family members was conducted as part of the nationwide Japan Hospice and Palliative Care Evaluation Study 5. The survey assessed the prevalence of unmet family-care needs, acceptability of care provided by various professionals through different communication modalities and eHealth literacy using the eHealth Literacy Scale.

Results: Participation was accepted by 498 bereaved family members. Among these respondents, 36% accepted asynchronous (text-based/AI-automated) communication for at least one aspect of family care. Acceptance rates were: video calls (85%), telephone (60%), text-based methods (34%) and AI-automated messages (12%). A substantial majority (79%) accepted care from professionals other than physicians and nurses. Acceptance increased with younger age and higher eHealth literacy. Significant unmet needs were identified, including information about high-volume cancer centres (45%) and consultation regarding patients' emotional distress (43%).

Conclusions: Multidisciplinary involvement and electronic communication methods were promising alternatives for delivering family care, particularly among younger families or those with higher eHealth literacy. Willingness to adopt AI-based support was relatively low, highlighting cultural and psychological barriers to AI adoption in Japan. The approaches could potentially help address family unmet needs while optimising the use of limited healthcare resources in palliative cancer care settings.

A legal obligation to commission palliative care was established in England in 2022; however, commissioners may struggle with what needs to be provided, how this should be funded, how effective services are and care quality. This is compounded by differing intersections between specialist and generalist palliative care across England. Challenges to be addressed include service specification, integration of healthcare Information Technology (IT) systems and funding for the implementation of an agreed national dataset of outcomes for specialist palliative care. Funding is also required to build connectivity, coordination and digital infrastructure. Engaged political and clinical leadership, supported by research capacity, is vital.