The American journal of hospice & palliative care最新文献

BackgroundHospice-eligible patients are vulnerable to adverse medication effects given their advanced illnesses and general older age. It is not known how often medications are not renal dose adjusted in hospice-eligible patients and which are frequently problematic. This study aims to identify commonly prescribed medications with significant renal clearance that are dosed too high and patient characteristics that increase the likelihood of occurrence.MethodsThis is a retrospective chart review of adult patients admitted to hospice care. Data collected included clinical/demographic data, renally cleared medications taken at time of hospice admission, and calculated renal function using several formulas. Descriptive statistics and binomial logistic regression were used to analyze data.ResultsOf 283 included charts, 27% had ≥1 medication dosed too high for renal function. The most common medications prescribed and not renal dose adjusted included tramadol, gabapentin, duloxetine, loratadine, cetirizine, famotidine, apixaban, rivaroxaban, metformin, trospium, and most antimicrobials. Increasing serum creatinine values and increasing number of renally cleared medications were associated with a higher likelihood of a medication dosed too high [OR, 1.702, 95% CI (1.257, 2.305), P < 0.001] and [OR, 1.856, 95% CI (1.517, 2.271), P < 0.001] respectively. Residing at home vs a facility was associated with a reduced likelihood of having a medication dosed too high [OR, 0.30, 95% CI (0.134, 0.673), P = 0.003.].ConclusionsHospice-eligible patients frequently have renally cleared medications prescribed and at doses too high for their renal function. Analgesics, over-the-counter antihistamines, anticoagulants, anticholinergics have potential for significant adverse effects and higher vigilance is needed.

BackgroundIntensive end-of-life (EOL) care is emotionally and financially burdensome, disproportionally negatively impacting racial and ethnic minorities, rural residents, and lower socioeconomic seniors.ObjectivesTo evaluate the impact of race, ethnicity, and rural residency on EOL Intensive Care Unit (ICU) stays, emergency department (ED) visits, 30-day readmissions, and Advanced Care Planning (ACP) in Colorado residents when controlling for comorbidities.MethodsThis retrospective cohort study analyzed data from the Colorado All-Payer Claims Database for 92,975 severely or chronically ill individuals (2018-2021). It used logistic regression models to evaluate associations between demographic variables and EOL health care utilization outcomes.ResultsICU Stays: Hispanic/Latino, Asian, and Black members had increased ICU stays compared to Whites (Adj. OR: 1.24;1.34;1.28: 95% CI). However, members without ACP and rural residents had lower ICU stays (Adj. OR: 0.67; 0.89: 95% CI). ED Visits: Hispanic/Latino, Asian, Black members, non-dually eligible members (Medicare Fee for Service (MFFS) + Medicaid), and rural residents had increased ED visits (Adj. OR: 1.29; 1.39; 1.19; 1.17; 2.04: 95% CI). Meanwhile, members without ACP or hospice care had lower ED visits (Adj. OR: 0.70; 0.75: 95% CI). 30-day Readmissions: Asian members and rural residents had increased 30-day readmissions (Adjusted OR: 2.42; 1.06: 95% CI). In contrast, those on MFFS and not on Medicaid, members without ACP, and those not in hospice care had decreased 30-day readmissions (Adj. OR: 0.69; 0.47; 0.83: 95% CI).ConclusionEOL racial, geographic, and socioeconomic disparities exist in Colorado, requiring urgent interventions for a more equitable health care system.

IntroductionAmerican Indian/Alaska Native (AI/AN) persons disproportionately suffer from end-stage kidney disease caused by diabetes (ESKD-D). Kidney transplant is the most desirable option to treating ESKD-D, but remains unattainable for many AI/AN persons, especially in rural South Dakota (SD). Additionally, palliative and hospice care options for AI/AN with any serious illness in SD are largely inaccessible. Moreover, receiving kidney transplant potentially affects hospice referral because of the desire to prolong transplant function. Therefore, the purpose of this study was to compare hospice use rates among AI/AN and non-Hispanic White (NHW) persons with ESKD-D prior to death and determine if differences in referral rates are present for those with and without a prior kidney transplant.MethodsRetrospective cohort analysis of United States Renal Data System data from 2000-2021. Data for persons with hospice care, transplant status, place of death, and race were analyzed using chi-squared tests with Yates' continuity correction and the Cochran-Mantel-Haenszel test.ResultsAI/AN persons with ESKD-D were less likely to receive hospice care prior to death compared to NHW persons in both transplant (P < 0.001) and non-transplant (P < 0.001) groups. When comparing transplant and non-transplant groups by hospice use, persons with no previous transplant were more likely to receive hospice care prior to death (P < 0.001).ConclusionThese results confirm the assumptions of significant differences in hospice care use among AI/AN vs NHW who have ESKD-D, including differences between those with a prior transplant. There is a need to expand palliative/hospice care services for persons with a prior kidney transplant.

BackgroundMoral distress (MD), the notion of not being permitted to act in a morally and ethically correct manner, is evident amongst oncologists caring for terminally ill patients. Oncologists often contend with complex decisions, such as withholding treatment and managing family distress. Sociocultural and individual considerations also influence an oncologist's perception of MD, which can vary in severity due to changing ethical, practical, clinical, moral and professional considerations and shifting contextual circumstances. Their impact compromises an oncologist's wellbeing, patient outcomes and care of their family. Recent data suggests long-term consequences to MD and alludes to a broader cost of caring that encompasses compassion fatigue, vicarious trauma, secondary traumatic stress and burnout.MethodsThis study aims to determine how oncologists in Singapore experience MD and the costs of caring through secondary analysis of interviews with 12 oncologists.ResultsAnalysis of the interview transcripts revealed the following domains: 1) sources of MD; 2) sources of the costs of caring; and 3) protective factors.ConclusionThis secondary analysis of Singaporean oncologists suggests that MD is not frequently an isolated experience; rather, it leads to growing distress amongst oncologists-contributing to a wider cost of caring. This then impacts oncologists' decisioning, actions, practice and career trajectories. Longitudinal structured training, establishing personalised support for all oncologists and creating a safe working environment supported by the host organisation are thus critical to ensure sustainable practice.

This study explores end-of-life care decisions across cultures by comparing advance directives (ADs) laws in the United States (U.S.) and Taiwan. Specifically, it examines the U.S.'s 1991 Patient Self-Determination Act (PSDA) and Taiwan's 2019 Patient Right to Autonomy Act (PRAA). By analyzing key legal differences and similarities, the study provides insights into improving end-of-life care policies and understanding how legal frameworks shape patient autonomy globally. This review utilized the keywords "United States or Taiwan," "Patient Self-Determination Act," "Patient Right to Autonomy Act," "advance directives," and "advance care planning," with searches restricted to English or Chinese publications since 1991. The analysis shows that both the U.S. and Taiwan view ADs as crucial for healthcare autonomy, enabling individuals to make decisions in advance and allowing healthcare agents to act on their behalf if they become incapacitated. However, ADs laws differ notably in their requirements, scope, completion processes, healthcare agent eligibility, portability, and promotional efforts. In the U.S., while various types of ADs are available (e.g., MOLST, POLST, Five Wishes), stricter regulations are needed to govern interactions between patients and healthcare agents to ensure that healthcare decisions align more closely with patients' preferences. Improving AD portability, particularly in emergencies, through cross-state recognition or digital sharing, is essential. For Taiwan, recommendations include enhancing palliative care practices and expanding ADs to include emotional and spiritual preferences. Integrating psychiatric ADs into Taiwan's PRAA could provide significant benefits. Additionally, reducing the costs associated with advance care planning and increasing AD awareness through active healthcare involvement would further strengthen patient autonomy.

BackgroundMany severe COPD patients are unaware of their treatment options and lack motivation for advance care planning. It is crucial to increase patient awareness regarding their chronic conditions.MethodsThe InformedTogether decision aid was used in outpatient clinical visits to inform patients about their COPD prognosis. Audio-recorded visits were analyzed for how denial, self-perceived health, and trust impacted patient motivation to make an advance care plan.ResultsOf the 26 patients, 4 (15.38%) showed an increase in motivation, 20 (76.92%) had no change, and 2 (7.69%) showed a decrease in motivation. Denial facilitated by physicians did not significantly affect motivation (p = 0.543). Self-perceived health also had no significant impact on motivation, with 68.00% rating their health as poor, 16.00% as fair, and 16.00% as good (p = 0.847). Trust in the physician's information was generally high, with 64.00% reporting high trust, but did not lead to an increase in motivation (p = 0.512).ConclusionDenial, self-perceived health, and trust did not significantly affect patient motivation to make an advance care plan. This study suggests that barriers to increasing motivation remain, and further research on external factors may be helpful to improve patient participation in end-of-life care planning.

Objective: In-hospital cardiac arrest (IHCA) is a common event with high morbidity and mortality. This study seeks to evaluate advance care planning (ACP) among hospitalized patients who experienced IHCA. Design: Single center retrospective cohort study. Measurement and Main Results: The primary objective was to compare whether certain clinical characteristics are associated with a physician's likelihood of having an ACP discussion with patients who subsequently have IHCA. We found that older age, White race, and higher GO-FAR score were associated with increased ACP documentation. In multivariate regression modeling, numerically higher GO-FAR score, ICU patients, hospitalization for ≥7 days, and having a normal mental status were consistently associated with ACP documentation (OR ∼2 for all). There was a persistent trend, significant in some models, to lower likelihood of ACP documentation for non-White patients. Among patients who had predicted low-to-very low likelihood of IHCA survival, most (56%) had no ACP documentation prior to IHCA. Conclusions: We found that the factors associated with an increased likelihood of ACP were age, ICU location, longer LOS prior to IHCA, higher GO-FAR score and normal mental status before IHCA. There was a worrying trend toward lower rates of ACP documentation among non-White patients. The overall rate of completion of ACP was low in patients with poor predicted IHCA outcomes. Ongoing efforts should continue to engage all patients in ACP irrespective of demographics, and there may be a role for utilizing standardized prognostication models to encourage ACP.

Substance use disorder in patients with cancer and other advanced illness is increasingly recognized as an emergent problem, and it has been associated with significant morbidity and mortality. The Palliative Recovery Engagement Program (P- REP) at the University of Pittsburgh Medical Center (UPMC), U.S.A, is an interdisciplinary clinic housed within an outpatient addiction program. It was formed in 2020 to care for individuals who have advanced illness, primarily cancer, who also experience substance misuse. We conducted semi-structured interviews with clinic patients to better understand their experience with pain management prior to arrival and while at P-REP. We identified factors that can influence the therapeutic relationship in this setting where conflict often predominates, such as a patient's coping mechanisms, their prior experiences with stigma, recovery programs, buprenorphine, and their ideas about abstinence, recovery, and the safety of their own patterns of opioid use. Notably, we found that clinicians who are familiar with these factors may feel more prepared to facilitate conversations, negotiate through shared decision making, and help maintain the therapeutic relationship, even when the provider and patient strongly disagree.

ObjectiveEnd-of-life doulas (EOLDs) offer non-medical support to patients and families, yet little is known regarding how knowledgeable and receptive gynecologic oncologists are to EOLDs.MethodsMembers of the New England Association of Gynecologic Oncologists (NEAGO) were surveyed regarding demographics and familiarity with and attitudes towards EOLDs. Descriptive statistics described demographics. Chi-square testing and Spearman's correlation coefficient were used for comparative analysis.ResultsThirty-nine of 85 NEAGO members completed the survey (response rate 46%). Most were physician gynecologic oncologists (95%) who practiced in academic settings (79%) and participated in end-of-life care (92%). Thirty-nine percent had heard of an EOLD. One clinician had a patient or family request EOLD services, but no one had personally worked with an EOLD. No one was familiar with the cost of EOLDs. After reading information regarding EOLDs, most agreed that EOLDs could be a valuable component of end-of-life care (87%) and they should be accessible and affordable to patients (85%). A majority reported they would be likely to recommend an EOLD to patients during the dying period (62%). A positive correlation was found between those who perceived EOLDs as valuable and their likelihood to recommend EOLDs to patients (r_s = 0.6, P < 0.001). Younger clinicians and those with fewer years of practice were also more likely to recommend EOLDs to patients.ConclusionKnowledge of and experience with EOLDs is limited among surveyed gynecologic oncologists. After education on their roles, many clinicians see value in their services and would recommend EOLDs to their patients.