The American journal of hospice & palliative care最新文献

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: 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.

Background: Antipsychotics and benzodiazepines are prescribed for hyperactive delirium despite their side effects and lack of supportive evidence. Valproic Acid (VPA) improves agitation without QTc prolongation, excessive sedation, and parkinsonism. However, high quality evidence for this is lacking in delirium. Methods: This retrospective study involved hospitalized patients seen by Palliative medicine from 10/1/2019 to 4/17/2020 who received VPA for at least 24 hours for hyperactive delirium. Patients were excluded if VPA was used for seizures or bipolar disorder. We hypothesized that VPA improves agitation and thus reduces the use of opioids, antipsychotics, and benzodiazepines. Results: Twenty patients, 50% women, and a median age of 81.5 years were treated. Nine had cancer, five dementia and two had strokes. The median daily VPA dose was 831.6 mg (IQR 671.4 -1016.4). Due to the small numbers, we did not find a statistically significant differences in benzodiazepine, opioid, or antipsychotic use on days 1, 2, or 3. VPA was used as monotherapy in 10 patients, with no additional antipsychotic or benzodiazepines needed. Eleven patients were on comfort care measures at the time of VPA initiation. Ten died in the hospital. Three were discharged home, and seven transferred to a skilled nursing facility. Discussion: This study explored the use of VPA in palliative care. VPA may be effective in treating aggitation. Randomized controlled trials are needed to validate VPA benefits in treating agitated delirium.

Orthodox Jewish patients with terminal illnesses have unique goals and desires, often driven by halakha (Jewish law and ethics) and cultural norms. We conducted a quality improvement project investigating the baseline perceptions and experiences of medical professionals who care for Orthodox Jewish patients with terminal illnesses. The survey included health care professionals who cared for Orthodox Jewish patients as part of Intensive Care Unit (ICU), Oncology, or Palliative Care and Hospice teams. The three main elements of the survey included respondent demographics, multiple choice selections, and a free-text section. A total of 73 medical professionals responded to the survey. Several important findings were noted. Compared to the general population, Orthodox Jewish patients with terminal illnesses are more likely to request aggressive measures at end-of-life and are less likely to have completed advanced directives and health care power of attorney documentation. They also do not always have a rabbinic authority involved in decision-making. Health care professionals highlighted strong religious and community support as positive elements of caring for this population and recommend that medical teams establish early and direct communication with rabbinic authorities for those patients for whom a rabbi's involvement is desired. These data inform ongoing next steps to improve the quality of care for these patients and their families.

There is an emerging need to provide high-quality pediatric palliative care and end-of-life care to children, adolescents, and young adults with life-limiting illnesses. Currently, there are no standardized quality measures supporting pediatric palliative care and end-of-life care patient outcomes. The aim of this literature review was to explore current quality measures utilized in pediatric palliative care and end-of-life care among pediatric patients with life-limiting illnesses within the conceptual framework of Comfort Theory. A comprehensive review of relevant articles resulted in 15 articles that met criteria and were evaluated. Included studies focused on pediatric patients with life-limiting illnesses receiving palliative care or end-of-life care. Articles related to children with acute illness, trauma, or accidental death were excluded. Emergent themes among quality measures were categorized into 7 domains: (a) Alleviation of distressing symptoms, (b) Structures and processes of care, (c) Health care utilization, (d) Location of death and bereavement care, (e) Patient and family experiences, (f) Psychological and spiritual care, and (g) Cultural, ethical, and legal considerations. These domains support the physical, psychospiritual, sociocultural, and environmental contexts of Comfort Theory. Quality measure research, development, and standardization should focus within the 7 domains identified for the promotion of comfort, equity, and accessible care.

Background: Patients who experience homelessness manifest poor cancer outcomes, often because of treatment delays. Few studies have used mixed methods to learn what happens at the patient and health care staff level to explain these delays. Methods: This single-institution, multi-site study interrogated the entire medical record system (thousands of patients annually) for homelessness and cancer diagnoses from January 1, 2019, through October 10, 2023. Records were abstracted for relevant quantitative and qualitative data; rigorous methods were used to analyze, integrate, and report findings. Results: Forty-three patients with a median age of 58 years (range: 32, 73 years) and 34 (79%) assigned male sex at birth are the focus of this report. The most common cancers include hematologic (n = 8), gastrointestinal (n = 8), and genitourinary (n = 8). Thirty-five patients (81%) initiated cancer therapy, and 27 (63%) manifested treatment delay (>4 weeks post-diagnosis). The median time to cancer therapy was 9 weeks (95% confidence interval: 4.6, 12 weeks). Qualitative themes that explain delays are as follows: (1) logistical challenges in communication between the patient and health care team ("lack of a cell phone"); (2) patient reluctance to receive care ("patient elected to leave Against Medical Advice"); and (3) medical challenges in providing care ("he was hospitalized after being found down and hypotensive"). Conclusions: This study confirms that initiation of cancer therapy is often delayed in patients who experience homelessness. It sheds light on reasons for delay - for example, lack of phone access, an observation which suggests that perhaps provision of a burner phone might help some patients.

BackgroundThis study reviewed the role of occupational therapist's in palliative and hospice care over the past 20 years.MethodsA scoping review following Arksey and O'Malley's five stages was undertaken using PubMed, OTseeker, Scopus, Elsevier, Cochrane Library-Medline, CINAHL, PsychInfo, Web of Science and Google Scholar.ResultsA total of 41 articles were reviewed. The most publications occurred in 2010, 2011, 2015, and 2023. The majority of the studies (48.7%) were of qualitative design. Various roles of occupational therapists have been defined in palliative care: discovering occupational meaning in the last periods of life and supporting occupational participation, management of persistent physical and psychological symptoms, especially pain and fatigue, improving or supporting the quality of life for individuals under palliative care, supporting mental well-being, supporting social participation, use of adaptive technologies, providing individuals with confidence and comfort. Occupational therapists also have various duties in maintaining palliative-hospice care at home include evaluating the individual at home and supporting home care and rehabilitation after discharge. Interventions for caregivers or supporting caregivers who have lost their roles, occupations or jobs in the care process are also among the roles of occupational therapists.ConclusionOccupational therapy within the context of palliative care aims to assist individuals in attaining their highest level of independence in important occupations. Occupational therapists play a crucial role in coordinating and facilitating safe transitions from the hospital to home, aiming to improve the overall quality of life and reduce hospital stays.

BackgroundIndividuals who do not show up for medical appointments can lead to unfavorable outcomes for both patients and health systems. Automated methods are available to confirm appointments in addition to patient service coordinator (PSC) telephone calls. This study aims to determine the no-show rates for automated methods of confirmation, in-person and virtual visits, and patients living in underserved areas.MethodsData was gathered retrospectively through electronic medical record review. Completed, canceled and no-show visits for in-person and virtual (telehealth) visits from January to June 2023 were collected along with automated and PSC reminders, and whether patients resided within community outreach zones (COZ), areas of healthcare underutilization.ResultsOf 8054 scheduled appointments with 2161 unique patients, there were 4563 (57%) completed, 3036 (38%) canceled, and 455 (6%) no-shows. Overall no-show rate was 6% (CI: 5%-6%). No-show rate for in-person visits was 5% (CI: 4%-6%); 9% (CI: 8%-11%) for virtual visits. Patients who confirmed by PSC telephone call had a significantly higher chance of no-show compared to those who did not confirm by other means (OR 1.57; 95% CI 1.23-2.01; P = 0.0003). Patients living within COZ had a significantly higher chance of no-show compared to patients living outside (OR 1.88; 95% CI 1.51-2.34; P < 0.0001). For virtual appointments, patients living within COZ had a significantly higher chance of no-show compared to patients living outside (OR 1.65; 95% CI 1.11-2.46; P = 0.0141).ConclusionPSC telephone calls, individuals living within COZ and virtual visits had higher no-show rates.

BackgroundIn 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?".MethodsGuided 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.ResultsOf 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.ConclusionCF 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.

BackgroundPatients enrolling in hospice care are asked their preferences for antibiotic treatment. There is little information regarding which patients are more likely to receive antibiotics. To better inform discussions, we sought to characterize the use of antibiotics in the outpatient hospice setting.MethodsWe performed a retrospective review of patients enrolled in outpatient hospice within the Mayo Clinic Health System from 1/1/2017 through 1/1/2023. We calculated what percent of patients received antibiotics based on Hospice Qualifying Condition (HQC), age at enrollment, sex, survival time, and Charlson Comorbidity Index and calculated adjusted odds ratios (aOR). We documented which antibiotics were prescribed based on HQC.ResultsOf 6452 patients identified, 1259 (19.5%) received antibiotic prescriptions. Cephalosporins were the most common class of antibiotics prescribed (22.8% of antibiotics prescribed), followed by fluoroquinolones (20.3%) and penicillin derivatives (14.9%). Patients with Pulmonary HQCs were most likely to receive antibiotics (28.6% aOR 1.85 [1.51-2.25]), those with neurologic HQCs were least likely (14.9% aOR 0.66 [0.53-0.83]). There was no difference of age for those receiving antibiotics (80.7 yr) vs those not receiving (80.3 yr [P = 0.25]), or for sex (male vs female aOR 1.10 [0.96-1.26). 4.6% of those surviving <7d received antibiotics (aOR .22 [0.17-0.29]), compared to 47.7% of those surviving >6mo (aOR 4.46 [3.50-5.69]).Discussion19.5% of patients will receive antibiotics during their hospice course, with more frequent prescriptions in those surviving longer periods and those enrolled for pulmonary conditions. It is important to clarify patient preferences regarding antimicrobial utilization at the time of hospice enrollment.