The American journal of hospice & palliative care最新文献

Background: Palliative care (PC) aims to enhance the quality of life for patients when confronted with serious illness. As stroke inflicts high morbidity and mortality, the integration of PC within acute stroke care remains an important aspect of quality inpatient care. However, there is a tendency to offer PC to stroke patients only when death appears imminent. We aim to understand why this may be by examining stroke patients admitted to a regional stroke centre who subsequently died and their provision of PC. Methods: We conducted a retrospective single-centre cohort study of patients who died during admission to the regional stroke centre at Sunnybrook Health Sciences Centre (SHSC) in Toronto, Ontario, Canada. Baseline demographics were assessed using means, standard deviations (SD), medians, interquartile ranges (IQR), and proportions. Descriptive statistics, univariate, and multivariate analyses were performed to ascertain relationships between collected variables. Results: Univariate modeling demonstrated that older age, being female, no stroke diagnosis at admission to hospital, ischemic stroke, and comorbidities of cancer or dementia were associated with a higher incidence of palliative medicine consultation (PMC), while admission from an acute care hospital and a Glasgow Coma Scale (GCS) coma classification were associated with a lower incidence of PMC. The multivariate model identified the GCS coma-related category as the only significant factor associated with a higher incidence of death but was non-significantly related to a lower incidence of PMC. Conclusion: These results highlight continued missed opportunities for PC in stroke patients and underscore the need to better optimize PMC.

Background: Resident physicians experience personal and professional stressors throughout training. These experiences may increase levels of burnout, depression, and grief. Understanding how these stressors impact trainees is essential for improving wellbeing during residency.

Objective: We examined the prevalence and associations between burnout, depression, and grief among a national sample of psychiatry resident physicians.

Methods: A survey including validated scales for burnout (Modified Maslach Burnout Inventory-Health Services Survey [MBI]), depression (Patient Health Questionnaire-9 [PHQ-9]), and grief (Traumatic Grief Inventory Self Report [TGSIR]) was distributed to 296 psychiatry program directors in January 2023 for dispersal to their respective residents.

Results: Fifty-seven participants completed the survey out of 245 participants who opened and started the survey (23.3%). All participants were current psychiatry residents. MBI scores averaged 21.2 (SD 6.5, range 11-40); 11 participants reported high levels of burnout (scores >27; 19.3%). PHQ-9 scores averaged 3.42 (SD 3.0, range 0-14), with 8 responses meeting the criteria for moderate depressive symptoms (scores >10-14; 14.0%). Suicidal ideation was reported by 5 of 57 participants (8.7%). TGISR scores averaged 12.2 (SD 11, range 0-43); no participants met the criteria for pathologic grief. TGISR scores were correlated with MBI (r = .30; P = .02) and PHQ-9 scores (r = .53; P < .0001). MBI scores were also correlated with PHQ-9 scores (r = .54; P < .0001).

Conclusions: Non-pathological grief was correlated with burnout and depression. 14% to 20% of psychiatry residents reported clinically significant levels of burnout and depression. Future studies should aim to further characterize burnout, depression, and grief in larger samples of trainees.

Mental health symptoms are common in the general population and are overrepresented in patients receiving palliative care and hospice services. This introduction to the special issue on Mental Health in Palliative Care and Hospice highlights the ongoing need for research and training to prepare our palliative care workforce to address the concerns of patients experiencing serious illness and mental health concerns. Multilevel approaches are needed to enhance understanding of mental health needs among people with serious illness. Public health outreach is needed within our communities, targeted support is needed for family caregivers, and structured training for palliative care and hospice clinicians is needed to enhance competent mental health in these settings.

Background: Hospice-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.

Methods: This 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.

Results: Of 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.].

Conclusions: Hospice-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.

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.

Introduction: Patients diagnosed with end-stage liver disease (ESLD) often struggle with a heavy symptom burden that compromises their quality of life. Introduction of specialty palliative care (PC) may help address these issues but is underutilized in ESLD. This study aimed to assess the performance of the surprise question (SQ) in this population as a potential screen to identify patients with a life expectancy of less than 12 months.

Methods: A retrospective cohort analysis was performed. In a previous study (COMPASS Trial, NCT03022630), attending hepatologists were asked the SQ: "Would you be surprised if this patient were to die in the next 12 months?" as a prompt to consider consultation to specialty PC. Here, we consider the full collection of SQ answers and reconcile against record of death to examine the accuracy of the SQ as a predictor in this patient population.

Results: The SQ had high sensitivity (93%) but low specificity (38%) for predicting 12-month mortality in ESLD patients. The SQ also had a positive predictive value of 42% and a negative predictive value of 92%. Patients who were SQ+ (physician responded: No, I would not be surprised) were more likely to die within the year than those who were SQ-.

Conclusion: In ESLD, the SQ may serve as a useful screening test to identify patients at higher risk of mortality which may prompt PC engagement.

Objective: Consultations conducted by spiritual health clinicians (SHC; also known as healthcare chaplains) offer a unique context for patients to express themselves and are associated with reduced stress and enhanced satisfaction. The language used during these consults may provide insights into emotions and recovery trajectories. This study aimed to characterize patient language in spiritual health consults and examine its relationship to mental health outcomes, evaluated within the Ecological Model of Recovery (EMR) framework.

Methods: SHCs conducted consultations with 212 patients in five acute-care hospitals in the urban south. Pre-consult distress and post-consult anxiety and depression were measured. Consults were audio recorded, transcribed, and analyzed using Linguistic Inquiry and Word Count (LIWC-22). Linguistic indicators of emotion and EMR-related variables were examined. Spearman's rank-order correlation and Mann-Whitney U tests assessed the relationship between patient language and mental health outcomes.

Results: Language reflecting confidence and discussions about lifestyle and religious topics were associated with lower post-consult anxiety and depression, highlighting the importance of positive self-perception and structured, meaningful activities in recovery. Language related to social connections was negatively associated with depression, while language indicative of differentiation or conflict correlated with higher depression levels.

Conclusion: This study underscores the relationship between patient language during spiritual health consultations and mental health outcomes, emphasizing the therapeutic value of expressive communication. Verbal expression plays a crucial role in emotional recovery, as linguistic patterns in healthcare settings can reflect and influence psychological well-being. Prospective research is needed to fully explore these effects.

Objectives: To evaluate the impact of patient and caregiver hospice care (HC) and palliative care (PC) beliefs and patient/caregiver belief-agreement on subsequent utilization of HC/PC among racially and ethnically diverse patients.

Methods: A prospective cohort study of newly diagnosed patients ≥18 years old with advanced lung cancer and their caregivers was conducted. Participants completed validated surveys at multiple points and electronic health records were reviewed to evaluate utilization. Logistic regression models were used: (i) to estimate the association between caregiver health belief composite scores and utilization of HC or PC; and (ii) to estimate the association between level of agreement between patient and caregivers, and utilization of HC or PC.

Results: Among the 43 patient/caregiver dyads enrolled in the study, 27 (63%) identified as Black and/or Latino (minoritized) and 16 (37%) as Non-Hispanic White (non-minoritized). Mean age was 65.2 ± 10.2 and 52.1 ± 15.2 years among patients and caregivers, respectively. Minoritized patients held more negative health beliefs (2.7 ± 6.7 vs. 7.1 ± 4.9; p = 0.02) than their non-minoritized counterparts however, they were more likely to use HC and/or PC (67% vs. 25%; p = 0.02). Level of health belief agreement between patients and caregivers was lower in minoritized vs non-minoritized dyads (mean (SD) Kappa: 0.31 (0.18) vs. 0.18 (0.18); p < 0.01). Caregiver beliefs and patient/caregiver agreement in beliefs did not predict utilization of HC/PC.

Conclusion: Minoritized lung cancer patients held more negative beliefs about HC/PC yet were more likely to receive HC/PC. Further work is needed to understand factors that impact utilization among diverse patients with advanced cancer.

Background: Patients 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.

Methods: We 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.

Results: Of 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]).

Discussion: 19.5% 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.

Background: Palliative care units are centers where comprehensive care is provided, primarily by nurses, but also by informal caregivers who are usually the patients' relatives. The difference is that nurses fulfill this duty professionally, and their levels of self-care and compassion are not expected to be affected by their work. In this regard, comparing the levels of compassion and self-care in patients' relatives and nurses will provide evidence to help raise awareness and support both groups.

Aims: This study aimed to determine the relationship between the self-care abilities and compassion of nurses and informal caregivers.

Design: This was a descriptive, cross-sectional study.

Settings/participants: The study was conducted between August 2023 and July 2024 in palliative care units in Istanbul. A total of 98 nurses and 96 informal caregivers participated in the study. They were administered the Exercise of Self-Care Agency Scale and the Compassion Scale.

Results: The mean compassion scores of the informal caregivers and nurses were high, with no significant difference (P > .05). However, a significant difference was observed in their self-care ability scores, with nurses scoring lower in self-care compared to informal caregivers (P < .05).

Conclusions: Nurses working in palliative care had a similar level of compassion as the primary relatives of the patients. However, it is concerning that the nurses had less ability to engage in self-care than the informal caregivers. This result indicates that nurses need support to enhance their self-care.