The American journal of hospice & palliative care最新文献

Objectives: Critical care is a place of frequent death, up to a quarter of those admitted die during admission. Caring for dying people provides many challenges, practically, professionally and personally. The aim of this study was to better understand the perspectives of staff caring for dying people in critical care and identify their priorities for improvement. Method: Three multidisciplinary focus groups of critical care staff at a large central London hospitals trust were facilitated with a semi structured format and digitally transcribed. Inductive thematic analysis was conducted to extract themes. Results: N = 34 (18 nursing, 7 allied health professionals, 6 medical, 3 clerical/administrative). The five themes were structured as priority statements: "We need to recognise" included the subthemes of being "sick enough to die" and potential rapid deteriorations in this setting; "We need to understand" with subthemes of perspectives on dying and prioritising time for conversations; "We need to connect" with subthemes of therapeutic relationship and physical presence; "We need to collaborate" with subthemes of critical care working and empowerment, and cross teams working; "We need support" with themes of experiencing support and making time to support others. Conclusion: We present an approach to identifying critical care departmental priorities for an end-of-life care improvement programme. The themes extracted will be used to evaluate systems for dying in critical care, aiming to empower staff to provide excellent care every time they look after a dying person. Relevance to Practice: This service evaluation identifies key priorities among critical care staff regarding end-of-life care. The insights can guide service improvements, such as tailored training and enhanced support for staff, to ensure better communication, collaboration, and quality care for patients at the end of life.

Introduction: American 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.

Methods: Retrospective 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.

Results: AI/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).

Conclusion: These 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.

Background: In their care of terminally ill patients, palliative care physicians and oncologists are increasingly predisposed to physical and emotional exhaustion, or compassion fatigue (CF). Challenges faced by physicians include complex care needs; changing practice demands, and sociocultural contextual factors. Efforts to better understand CF have, however, been limited. We propose a systematic scoping review (SSR) to determine "What is known about theories of CF in physicians?".

Methods: Guided by the PRISMA-based Systematic Evidence-based Approach (SEBA) methodology, our SSR comprised searches for articles published between 1 January 2000 and 31 December 2023 on MEDLINE, EMBASE, PsycINFO, Wiley, CINAHL and Google Scholar databases. Both thematic and content analyses were carried out.

Results: Of the 10 505 titles identified, 80 articles were included. 15 current theories of CF were evaluated, leading to two key domains: theories of CF and theories related to the costs of caring. Overall, theories of CF evolved from Figley's model with gradual encompassing of moral distress, vicarious trauma and burnout, alongside the inclusion of individual characteristics, decisioning and nous in later theories.

Conclusion: CF was found to be part of a wider cost of caring that links clinical experiences with self-concepts of personhood and identity. The Ring Theory of Personhood has been able to shed light on how physicians will respond to such experiences and is key to guiding physician support and the creation of nurturing working environments.

Introduction: Palliative care (PC) education is not uniformly provided across U.S. medical schools. While PC competencies for medical students have been articulated, no student-facing, unifying framework for competency-based PC learning exists.

Methods: In 2022, we developed a student-facing organizing framework (the "6 Ps") based on existing PC competencies and created a pocket card introducing foundational PC concepts organized within the 6 Ps framework. In 2023, we provided a mandatory 15-minute session to introduce the 6 Ps and pocket card to the first-year class of our large, urban medical school. We provided voluntary pre- and post- session surveys to evaluate usability and impact of the framework and pocket card.

Results: One hundred-twenty students of the 204-student class (59%) attended. Survey response rate was 106/120 (88%) pre-session and 101/120 (84%) post-session. Following the session, students agreed the 6 Ps was a good framework for conceptualizing PC (95/101; 94%), that the pocket card was understandable (96/101; 95%), and they would use the pocket card to teach fellow students about PC (85/101; 84%). Nearly all students endorsed learning novel concepts (95/100; 95%). Pre/post session comparison of self-assessed confidence approaching hypothetical clinical tasks, such as educating a patient about PC and hospice, revealed significant improvement (P < .01).

Discussion: First-year medical students were able to use the 6 Ps framework and pocket card after a brief introduction, endorsing new learning and demonstrating significant gains in knowledge and self-assessed confidence. Medical educators across schools may consider adopting this novel tool and approach to introduce or support student learning about PC.

Background: Nausea and vomiting significantly impact the quality of life in palliative care. Due to various underlying causes, treatment approaches vary. However, scientific evidence on pharmacotherapeutic management is limited, complicating treatment decisions. Objective is to assess the current antiemetic treatment approach in palliative care in Germany.

Methods: A retrospective observational study (15 months) was conducted, evaluating clinical records of adult patients admitted to palliative care in a German hospital. Symptom burden (Integrated Palliative care Outcome Scale (IPOS®)), suspected aetiology, antiemetics, treatment quality and drug-related problems (DRPs) were evaluated.

Results: We included 330 patients (median age 71 years, 50.9% female), of which 172 (52%) experienced nausea/vomiting in 230 treatment episodes. Symptoms were more prevalent in cancer-patients (P = 0.002) and women (P = 0.002). Main aetiologies were intestinal obstruction (59/230, 25.7%), hypomotility (31/230, 16.1%), and raised intracranial pressure (23/230, 10.0%). Nearly 70% experienced a reduction of symptom burden within the first 3 days, with faster symptom relief and shorter episodes in cancer patients compared to non-cancer patients (median length 3d vs 2d). DRPs were documented in 213/230 episodes (92.6%), indicating high interaction potential of antiemetics (87.4%). Manifest DRPs affected patients due to ineffective treatment (29.0%) or side effects (6.5%).

Conclusions: One-third experienced inadequate symptom control with the current treatment, underscoring the complexity of managing nausea/vomiting in palliative care and the need for a systematic approach. This study emphasizes the importance of evidence-based guidelines and further research into underutilized antiemetics, along with improved medical education in an interdisciplinary team to enhance treatment quality.

Objectives: In Italy a recent law was approved for providing patients' wishes regarding end of life issues, commonly referred internationally to as "living wills", (Dichiarazione anticipata di trattamento, DAT). Regardless of this official document, advance care planning (ACP) is often used in a palliative care setting to share the treatments to start, to continue, to withdraw, thus preventing the stress on an acute decision. The aim of this study was to assess DAT and ACP in patients with amyotropic lateral sclerosis admitted to home palliative care. Methods: Patients consecutively admitted to speciliazed home palliative care were prospectively assessed. The presence of DAT or ACP was recorded. Results: Sixty-eight patients were enrolled in the period taken into consideration. No patient had drown up DAT, and only one patient provided his ACP prior to home palliative care admission. Along the course of home palliative care care assistance, 30.9% of patients provided their ACP. Discussion: In Italy DAT resulted scarcely widespread, despite an existing law, as no patient officially provided their indication on end of life issues. In addition, ACP was given only after starting specialized home palliative care in less than 1/3 of patients. Home palliative care seems to be a fundamental resource for improving communication and soliciting expression of patients' wishes regarding end of life issues.

Objectives: To explore American Muslims' perceptions and experiences regarding hospice care within the United States.

Methods: A qualitative descriptive study of 11 participants, including one patient and ten family caregivers. Data was collected through semi-structured interviews and analyzed using a framework approach to identify key themes related to perceptions, ethical concerns, and experiences with hospice care.

Results: Three primary themes emerged: 1) notions of when hospice care should be sought; 2) Islamic ethical concerns about sedation and nutrition, and 3) positive experiences with hospice care accommodating religious beliefs and providing support. Participants' perceptions of the need for hospice care varied, though many associated it with the last hours or days of life. Ethical concerns emerged around the use of medications like morphine, which could lead to sedation and interfere with religious practices, such as prayer and a final testification of faith. Additionally, the ethical concerns regarding nutrition and hydration for terminally ill patients raised questions about the alignment of such practices with Islamic bioethical values, which emphasize both preserving life and avoiding harm. Positive experiences included respect for religious beliefs, Qur'an recitations, and accommodation of prayer times.

Conclusion: Misconceptions about hospice conflicting with religious practices and Islamic ethical concerns may influence the acceptance and utilization of hospice care within the American Muslim community. Tailored educational initiatives and the integration of religious values into hospice care can foster informed decision-making, enhance patient satisfaction, and improve overall care outcomes.

Hospice can improve end-of-life (EOL) outcomes in U.S. nursing homes (NHs). However, only one-third of eligible residents enroll, and substantial variation exists within and across NHs related to resident-, NH-, or community-level factors. We conducted a review of English-language, peer-reviewed articles 2008 to 2023 describing this variation in NH hospice use to characterize disparities and inform educational and quality initiatives to improve EOL care in NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We screened 1595 records, reviewed 82 articles and included 13 articles. Eleven used pre-2009 data. Six evaluated national data and 7 used regional (n = 1), state (n = 4), or local (n = 2) data. One assessed hospice referral, 10 hospice use, and 3 length-of-stay. Twelve conducted regression analyses; 1 stratified by race, another evaluated interaction terms, and a third compared racial differences within-and between-facilities. Unadjusted and adjusted differences were evaluated by resident race-and-ethnicity (n = 6 unadjusted, n = 10 adjusted, respectively), sex (n = 5, n = 9), or payor (n = 1, n = 4), or by NH race-mix (n = 1, n = 2), ownership (n = 1, n = 7), payor-mix (n = 1, n = 5), or urban/rural location (n = 1 adjusted). Unadjusted differences showed lower hospice use by Non-White residents and varied results by sex. Studies adjusting for resident-, NH-, and community-level factors found lower hospice use among male residents, Black/Non-White residents, and residents of rural NHs, with mixed results by payor and ownership. Results were mixed for hospice referral and length-of-stay. These findings suggest complex influences on NH hospice use. Further study is warranted to identify targets for improving hospice access.

Hospital readmissions within 30 days are a significant concern due to their negative impact on patient outcomes and healthcare system costs.¹ This retrospective study explores the impact of palliative medicine consultation on reducing readmission rates for patients with severe, life-limiting illnesses. Real-world data from a 21-hospital system was analyzed for six specific diagnoses, including heart failure, sepsis, pneumonia, and chronic obstructive pulmonary disease. The study found a statistically significant reduction in readmissions for patients with sepsis, pneumonia, heart failure and (to a lesser extent) stroke who received palliative medicine consultation compared to those who did not. The findings suggest that palliative medicine consultation for these patients leads to reduced readmission and implies potential improved quality outcomes and cost savings. This study highlights the potential of palliative medicine as a multifactorial approach to reduce readmissions and potentially improve patient outcomes in the future.

Objectives: Anticipatory grief is associated with post-bereavement grief; however, reports on the influence of pre-loss depression are limited. Therefore, we investigated the association between the anticipatory grief of family members and post-loss and post-depression grief adjusted for pre-loss depression. Methods: This cohort study included the family members of dying patients with cancer. Questionnaires were distributed to them during hospitalization in four inpatient palliative care units from 2016 to 2017. We also administered follow-up questionnaires after their bereavement in 2018. The pre-bereavement questionnaire consisted of three items from the Anticipatory Grief Scale for Families Caring for a Terminally Ill Person for assessing anticipated grief and the Patient Health Questionnaire 9 for assessing depression. The Brief Grief Questionnaire was used to assess post-loss grief. Results: We distributed 181 pre-bereavement questionnaires to the family members; 112 (62%) responded to the pre-bereavement survey, out of which 71 (63%) responded to the post-bereavement survey. Anticipatory grief was significantly associated with pre-loss (ρ = 0.37, ρ < 0.001) and post-loss (ρ = 0.24, P = 0.009) depression and marginally associated with post-loss grief (ρ = 0.15, P = 0.10). Pre-loss depression was also significantly associated with post-loss depression (ρ = 0.50, P < 0.001) and post-loss grief (ρ = 0.41, P < 0.001). However, anticipatory grief was not significantly associated with post-loss depression (P = 0.35) and post-loss grief (P = 0.65) after adjusting for pre-loss depression. Significance of Results: Bereaved families who experienced anticipatory grief had worse post-bereavement depression. However, this association was not statistically significant after adjusting for pre-bereavement depression. Post-bereavement depression may be in a continuum with pre-loss depression, and anticipatory grief does not independently affect post-loss reactions.