The American journal of hospice & palliative care最新文献

Background: Do Not Attempt Resuscitation (DNAR) orders allow patients with life-threatening conditions to decline resuscitation efforts should the need arise. The American Society of Anesthesiologists (ASA) recommends discussions with patients on their code status to clarify and honor their goals of care perioperatively. This project sought to determine the prevalence of DNAR orders and to identify the demographics and potential clinical predictors of DNAR status at the beginning and end of admission, which would help anesthesiologists at our center facilitate these discussions.

Methods: Factors associated with DNAR status at beginning and at end of hospital stay were determined through univariate logistic regressions. For DNAR status at beginning and end of hospital admission, variables assessed were age at arrival, race, sex, palliative consult, use of palliative care service, length of stay in days, presence of surgery, presence of emergent surgery, care level, and medical service.

Results: Approximately 2.4 percent of the sample had an active DNAR order at the beginning of their hospital admission compared to 7.4 percent at the end of hospital admission. Factors significantly associated with DNAR status at the beginning of the hospital stay were consistent with prior literature (age, palliative care consult or service). However, factors significantly associated with DNAR status at the end of hospital stay that were notable included length of stay, undergoing emergent surgery, higher level of care, and being on the oncology service and medical respiratory intensive care unit.

Conclusions: This retrospective study allows anesthesiologists at our institution to identify patients who may benefit from a more comprehensive perioperative discussion about code status based on certain clinical characteristics, which may improve quality of care by preventing unwanted resuscitative measures that do not align with a patient's goals of care.

Background: Many 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.

Methods: The 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.

Results: Of 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).

Conclusion: Denial, 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.

Background: Gaps in communication of end-of-life care preferences increase risk of patient harm. Adoption of oncology practice guidelines advocating serious illness communication for patients with advanced cancer is limited.

Objectives: (1) Increase Serious Illness Conversation (SIC) use across oncology teams via an interdisciplinary quality improvement (QI) approach and (2) assess patient reported shared decision making (SDM) experiences with clinicians engaged in SIC implementation.

Design: QI methodology was applied to spread the implementation of SIC across 4 oncology teams. CollaboRATE scores were used to evaluate patient reported outcomes of SDM for patients with advanced cancer.

Settings/subjects: The SIC QI initiative was a component of the Promise Partnership Learning Health System (PPLHS) piloted in the Dartmouth Cancer Center, Lebanon, NH, USA.

Measurements: (1) The percentage of eligible patients with documented SIC and (2) a comparison of a patient reported measure of SDM (CollaboRATE) among SIC eligible patients in encounters with providers who took part in the implementation versus those who did not.

Results: Oncology teams screened a total of 538 patients, identified 278 eligible patients, and completed 144 SIC conversations. The teams improved the proportion of documented SIC among eligible patients from near 0% to a collective frequency of 52%. For clinicians' top-box CollaboRATE scores, a chi-squared test demonstrated a statistically significant association between providers implementing SIC into practice and patient reported shared decision making (.16, p = .031).

Conclusions: This approach allows for tailoring of iterative improvement cycles to mitigate barriers and improve the practice of SIC among oncology teams.

Numerous neurosurgical (NSG) conditions entail high morbidity, mortality, and prolonged ICU stays. Palliative care (PC) serves to alleviate suffering, align treatment with patient preferences, and is linked to enhanced patient and family outcomes as well as reduced care costs. Notably, no studies have addressed demographic and clinical factors associated with PC receipt in NSG patients. Our aim is to identify characteristics and outcomes, particularly end of life outcomes, of hospitalized NSG patients associated with a PC consult compared with usual NSG care. A retrospective chart review was performed of patients admitted to the NSG service from January 1, 2017 to December 31, 2018 at the University of Iowa Hospitals & Clinics. Data regarding demographics, clinical outcomes, and GOC and ACP documentation were collected. The most common reasons for a PC consult were goals of care, end of life issues, and comfort care. Of 121 total decedent patients, 97 (80.2%) had PC referrals. Patients with a PC referral had longer hospital stays (10.3 days vs 4 days) and had the majority of care in the ICU (90.7% vs 83.3%). However, fewer PC patients died in the ICU (42.3% vs 75%) and more had PCA/NCA use (51.5% vs 8.3%), code status changes to DNR (90.7% vs 62.5%), GOC documented (78.4% vs 0%) and ACP documentation (35.1% vs 16.7%). In conclusion, in NSG patients, the integration of PC may contribute to improved end-of-life care.

Background. Despite the potential of palliative care (PC) to enhance the quality of life for patients with advanced dementia, there is limited knowledge of its inpatient utilization patterns. This study investigated inpatient PC consultation utilization patterns and evaluated its impact on hospital length of stay (LOS) and medical costs among older patients diagnosed with Alzheimer's Disease and Related Dementia who were at a high risk of mortality (ADRD-HRM). Methods. Using the 2016-2019 National Inpatient Sample database, we conducted multivariable logistic regression analyses to identify individual and hospital characteristics influencing PC consultation utilization. We subsequently performed generalized linear models to estimate LOS (using Poisson distribution) and hospital charges (via log-transformation). Results. Our sample encompassed 965,644 hospital discharges (weighted n = 4,828,219) of patients aged 65 years and above with ADRD-HRM. Among them, 14.6% received inpatient PC. There was a notable uptrend in PC consultation utilization from 13.3% in 2016 to 16.3% in 2019 (p trend<.001). Factors positively influencing and associated with PC utilization included patients that are older, non-Hispanic White, with higher income, receiving care from teaching hospitals, and facilitated with greater bed capacity (all P < .05). Although patients who received PC were more likely to have 3.0% longer LOS (P < .001), they had 19.2% lower hospital charges (P < .001). Conclusions. PC substantially reduced hospital expenditures for older patients with ADRD-HRM, but the prevalence remained low at 14.6% in the study period. Future studies should explore the unmet needs of patients with lower sociodemographic status and those in rural hospitals to further increase their PC consultation utilization.

Background: Some Japanese patients with cancer pain have negative beliefs regarding opioid therapy. The Japanese version of the Barriers Questionnaire II (JBQ-II) determines barriers to cancer pain management. Few studies reported JBQ-II scores in Japan, and none focused on pharmacists. Accordingly, we aimed to explore the relationship between health care professionals' knowledge of and willingness to use opioids, and their JBQ-II scores. Additionally, the variances in JBQ-II scores among nurses, hospital pharmacists, and pharmacy pharmacists were assessed.

Methods: This cross-sectional survey employed the JBQ-II for nurses and pharmacists in hospitals and pharmacies across Japan. Participants were requested to respond to the JBQ-II concerning their affiliation, knowledge of opioid analgesics, and willingness to utilize these drugs for medical practice.

Results: A total of 55 hospital pharmacists, 25 pharmacy pharmacists, and 24 nurses responded to the survey. The group-knowledgeable about medical use of narcotics had significantly lower total JBQ-II scores (25.43, standard deviation [SD]: 15.11) than those had by the group with insufficient knowledge (34.50, SD: 18.41). There was no statistically significant difference in total JBQ-II scores among those willing to use opioids medically. The total JBQ-II scores of hospital pharmacists, pharmacy pharmacists, and nurses were 31.00 (SD: 15.11), 33.96 (SD: 19.25), and 27.21 (SD: 15.56), respectively. However, the differences were not statistically significant.

Conclusions: Health care professionals in Japan with knowledge about opioids for medical purposes had a significantly lower total JBQ-II score than those with insufficient knowledge. Thus, health care professionals' knowledge plays a crucial role in reducing barriers to using narcotic drugs.

Background: Palliative care can enhance quality of life during a terminal hospitalization. Despite advances in diagnostic and treatment tools, blood cancers lag behind solid malignancies in palliative use. It is not clear what factors affect palliative care use in blood cancer. Methods: We used the 2016 to 2019 National Inpatient Sample to identify demographic and socioeconomic factors associated with receiving palliative care among patients over age 18 with any malignant hematological diagnosis during a terminal hospitalization lasting at least 3 days, excluding those receiving a stem cell transplant. Results: Palliative care use was documented 54% of the time among 49,720 weighted cases (9944 distinct individual hospitalizations), approximately evenly distributed across the years 2016-2019. Palliative care use was lowest in 2016 (51%) and highest in 2018 (58%), and increased with age, reaching 58% for those 80 years and older. Men and women were similarly likely to receive care. Patients of Hispanic ethnicity and African Americans received less palliative care (47% and 49%, respectively), as did those insured by Medicaid (48%), and those admitted to small or rural hospitals (52% and 47%, respectively). Charges for hospitalizations with palliative care were 19% lower than for those without it. Conclusions: This study highlights disparities in palliative care use among blood-cancer patients who died in the hospital. It seems likely that many of the 46% who did not receive palliative care could have benefitted from it. Interventions are likely needed to achieve equitable access to ideal levels of palliative care services in late-stage blood cancer.

Context: Insight into patients' personal values, wishes, and needs (VWN) by clinicians is essential to guide appropriate palliative care. Objective: To gain insight into the exploration and monitoring of the VWN of patients with advanced cancer during the illness trajectory by hospital oncology clinicians. Method: A generic qualitative study was conducted from February 2022 to July 2022. Specialized nurses, nurse practitioners and medical specialists (in training) providing care to adult patients with advanced cancer were recruited at an outpatient clinic in a Dutch academic hospital. Data were collected using in-depth semi-structured interviews and participatory observations of outpatient clinic consultations. Data were analyzed collaboratively by two researchers using thematic analysis. Results: Eleven clinicians, aged 33-64, 8 females, participated; 7 interviews and 13 observations were conducted. How clinicians explored and monitored patients' VWN was based on their opinions, originating from the clinicians' personal values and work experiences. These were influenced by the local collaboration. Three key opinions were identified: (1) providing safety, (2) supporting medical decision-making, and (3) ensuring alignment. Individual clinicians' approaches varied. The alignment of care and treatment with the patient's VWN was observed to be limited. Conclusion: Clinicians acknowledged the importance of exploring and monitoring patients' VWN but lacked a systematic approach in discussing these topics. Patients should be actively engaged in communication regarding their VWN rather than primarily being provided with medical information. Patient-Reported Outcome Measures may be beneficial in facilitating communication regarding the patient's VWN and could improve appropriate palliative care in hospital cancer care.

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Background: Ketamine has been used to control refractory cancer pain as an adjuvant to opioids. We conducted a prospective phase II study to investigate the efficacy and safety of 5-day continuous intravenous infusion (CIVI) of Ketamine in terminally ill cancer patients with refractory cancer pain.

Methods: Hospitalized terminally ill cancer patients with refractory cancer pain were enrolled. Refractory cancer pain was indicated by requirements for 4 or more rescue opioids or pain intensity using numerical rating scale > personalized pain goal (PPG) despite of intravenous morphine equivalent daily dose (IV MEDD) ≥ 120 mg/day. The CIVI of ketamine was increased from .05 mg/kg/hour to .5 mg/kg/hour by .05 every 8 hours if pain intensity exceeded PPG or if number of rescue opioids ≥2 during prior 8 hours was required. The primary end-point was overall pain response rate, which indicates complete response (both rescue opioid ≤3/day and pain intensity ≤ PPG) plus partial response (rescue opioid ≤3/day), without unacceptable toxicities.

Results: Among 21 eligible patients enrolled between September 2019 and January 2023, 20 were analyzed. Most pain mechanisms were mixed type (n = 15, 75%), with neuropathic component (n = 17, 85%). The baseline background opioids were IV MEDD 186 mg/24hour (range, 124-592), number of rescue opioids was 6 (IQR, 5-9), and median PPG was 4 (IQR, 3-4). The overall pain response rate was 50% (n = 10) including 40% (n = 8) for complete pain response and 10% (n = 2) for partial pain response.

Conclusion: This study showed efficacy of gradually increasing CIVI of ketamine for terminally ill cancer patients with refractory cancer pain. CIVI of ketamine could be a useful tool in these patients considering the limited treatment options. (NCT03362073, Initial Release: November 15, 2017).