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da Silveira MRM, Forte DN. Palliative care and neurology: a path to neuropalliativism. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:328-335. [PMID: 35976309 PMCID: PMC9491435 DOI: 10.1590/0004-282x-anp-2022-s119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
This article aims to expand the understanding of how it is possible to alleviate suffering and enable a dignified life trajectory for patients with progressive neurological diseases or with severe and permanent neurological impairment. The four most common disease trajectories described for people with chronic and progressive disease used to advance care planning, Brazilian normative ethical resolutions, evidence-based benefits of palliative care (PC), as well as particularities of PC in neurology, such as neurological symptom control, caring for existential and psychological suffering, care provider's needs and particularities of pediatric neurologic PC are reviewed.
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Affiliation(s)
- Mariana Ribeiro Marcondes da Silveira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Dor e Cuidados Paliativos, São Paulo SP, Brazil
| | - Daniel Neves Forte
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Emergências Clíncias, São Paulo SP, Brazil
- Hospital Sírio-Libanês, Núcleo de Cuidados Paliativos, São Paulo SP, Brazil
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52
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Taylor LP, Besbris JM, Graf WD, Rubin MA, Cruz-Flores S, Epstein LG. Clinical Guidance in Neuropalliative Care: An AAN Position Statement. Neurology 2022; 98:409-416. [PMID: 35256519 DOI: 10.1212/wnl.0000000000200063] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lynne P Taylor
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL.
| | - Jessica M Besbris
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - William D Graf
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Michael A Rubin
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Salvador Cruz-Flores
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Leon G Epstein
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
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53
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Harrison KL, Garrett SB, Gilissen J, Terranova MJ, Bernstein Sideman A, Ritchie CS, Geschwind MD. Developing neuropalliative care for sporadic Creutzfeldt-Jakob Disease. Prion 2022; 16:23-39. [PMID: 35239456 PMCID: PMC8896185 DOI: 10.1080/19336896.2022.2043077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We aimed to identify targets for neuropalliative care interventions in sporadic Creutzfeldt-Jakob disease by examining characteristics of patients and sources of distress and support among former caregivers. We identified caregivers of decedents with sporadic Creutzfeldt-Jakob disease from the University of California San Francisco Rapidly Progressive Dementia research database. We purposively recruited 12 caregivers for in-depth interviews and extracted associated patient data. We analysed interviews using the constant comparison method and chart data using descriptive statistics. Patients had a median age of 70 (range: 60–86) years and disease duration of 14.5 months (range 4–41 months). Caregivers were interviewed a median of 22 (range 11–39) months after patient death and had a median age of 59 (range 45–73) years. Three major sources of distress included (1) the unique nature of sporadic Creutzfeldt-Jakob disease; (2) clinical care issues such as difficult diagnostic process, lack of expertise in sporadic Creutzfeldt-Jakob disease, gaps in clinical systems, and difficulties with end-of-life care; and (3) caregiving issues, including escalating responsibilities, intensifying stress, declining caregiver well-being, and care needs surpassing resources. Two sources of support were (1) clinical care, including guidance from providers about what to expect and supportive relationships; and (2) caregiving supports, including connection to persons with experience managing Creutzfeldt-Jakob disease, instrumental support, and social/emotional support. The challenges and supports described by caregivers align with neuropalliative approaches and can be used to develop interventions to address needs of persons with sporadic Creutzfeldt-Jakob disease and their caregivers.
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Affiliation(s)
- Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, USA.,Philip R. University of California, San Francisco, USA.,Global Brain Health Institute, University of California, San Francisco, California, USA
| | | | - Joni Gilissen
- Global Brain Health Institute, University of California, San Francisco, California, USA.,End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (Vub), Belgium
| | - Michael J Terranova
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Alissa Bernstein Sideman
- Philip R. University of California, San Francisco, USA.,Global Brain Health Institute, University of California, San Francisco, California, USA.,Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- Division of Geriatrics, University of California, San Francisco, USA.,Global Brain Health Institute, University of California, San Francisco, California, USA.,The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
| | - Michael D Geschwind
- Global Brain Health Institute, University of California, San Francisco, California, USA.,Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
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54
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Sarmet M, Cavalcanti de Oliveira ERN, Cirne Franco H, Zeredo JL, Mehta AK. The Current State of Neuropalliative Care in Brazil: Trends in Representation and Advocacy. J Palliat Med 2022; 25:343-344. [PMID: 35230899 DOI: 10.1089/jpm.2021.0614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Max Sarmet
- Department of Palliative Care, Hospital de Apoio de Brasília, Brasília, Brazil.,Department of Neurology, Tertiary Referral Center of Neuromuscular Diseases, Hospital de Apoio de Brasília, Brasília, Brazil.,Graduate Department of Health Sciences and Technologies, University of Brasília, Brasília, Brazil
| | | | - Hamilton Cirne Franco
- Department of Neurology, Tertiary Referral Center of Neuromuscular Diseases, Hospital de Apoio de Brasília, Brasília, Brazil
| | - Jorge L Zeredo
- Graduate Department of Health Sciences and Technologies, University of Brasília, Brasília, Brazil
| | - Ambereen K Mehta
- Palliative Care Program, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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55
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Neuro-oncology and supportive care: the role of the neurologist. Neurol Sci 2022; 43:939-950. [DOI: 10.1007/s10072-021-05862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/28/2021] [Indexed: 11/29/2022]
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56
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Kluger BM, Kramer NM, Katz M, Galifianakis NB, Pantilat S, Long J, Vaughan CL, Foster LA, Creutzfeldt CJ, Holloway RG, Sillau S, Hauser J. Development and Dissemination of a Neurology Palliative Care Curriculum: Education in Palliative and End-of-Life Care Neurology. Neurol Clin Pract 2022; 12:176-182. [PMID: 35747891 PMCID: PMC9208408 DOI: 10.1212/cpj.0000000000001146] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/09/2021] [Indexed: 11/15/2022]
Abstract
ABSTRACTDespite increasing awareness of the importance of a palliative care approach to meet the needs of persons living with neurologic illness, residency and fellowship programs report meeting this educational need due to a limited pool of neuropalliative care educators and a lack of adequate educational resources. To meet this need, a group of experts in neuropalliative care and palliative medicine leveraged resources from the Education in Palliative and End-of-life Care (EPEC) program and the National Institutes of Nursing Research (NINR) to create a library of modules addressing topics relevant for neurology trainees, palliative medicine fellows and clinicians in practice. In this manuscript, we describe the development and dissemination plan of the Education in Palliative and End-of-life Care Neurology (EPEC-N) program, initial evidence of efficacy, and opportunities for neurology educators and health services researchers to utilize these resources.
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Affiliation(s)
- Benzi M Kluger
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Neha M Kramer
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Maya Katz
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Nicholas B Galifianakis
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Steven Pantilat
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Judith Long
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Christina L Vaughan
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Laura A Foster
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Claire J Creutzfeldt
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Robert G Holloway
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Stefan Sillau
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Joshua Hauser
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
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Oliver D. Neuropalliative care: Defining an emerging field. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:17-31. [PMID: 36055714 DOI: 10.1016/b978-0-323-85029-2.00008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Palliative care is increasingly becoming an established part of medical care, providing the holistic assessment and management of the person at the center of care-physical, psychological, social, and spiritual. This had originally been primarily provided for people with terminal cancers but in the last 50 years, this care has extended to caring for people with issues throughout disease progression and for all diagnoses, including neurologic diseases. Palliative care in fact is now included within guidelines and standards for many neurologic diseases. Palliative care may be delivered as an approach provided by all health and social care professionals; by focused care provided within neurology; and through the involvement of specialist palliative care and neuropalliative care for more complex issues. The education of neurologists and palliative care specialists is essential to enable all to be aware of the issues faced by patients and their families and provide adequate support for patients, families, and healthcare professionals. In this way, the quality of life can be maintained as much as possible and patients are able to die with as little distress as possible, with their families and carers supported.
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Affiliation(s)
- David Oliver
- Tizard Centre, University of Kent, Canterbury, United Kingdom.
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58
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Kluger BM, Miyasaki JM. Key concepts and opportunities. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:3-15. [PMID: 36055718 DOI: 10.1016/b978-0-323-85029-2.00014-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neuropalliative care is an emerging field dedicated to applying palliative care approaches to meet the needs of persons living with neurologic illness and their families. The development of this field acknowledges the unique needs of this population, including in terms of neuropsychiatric symptoms, the impact of neurologic illness on personhood, and the logistics of managing neurologic disability. In defining the goals of this field, it is important to distinguish between neuropalliative care as an approach to care, as a skillset, as a medical subspecialty, and as a public health goal as each of these constructs offers their own contributions and opportunities. As a newly emerging field, there are nearly unlimited opportunities to improve care through research, clinical care, education, and advocacy.
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Affiliation(s)
- Benzi M Kluger
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Janis M Miyasaki
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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59
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Gursahani R, Lorenzl S. International models of neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:73-84. [PMID: 36055721 DOI: 10.1016/b978-0-323-85029-2.00012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Can equitable Neuropalliative care (NpC) be delivered globally? This chapter surveys existing services and ground realities in different parts of the world. In many countries, universal healthcare (UHC) seems to have been a precondition for the establishment of palliative care (PC). PC has been recognized as a basic human right as a part of UHC. Quality of Death and PC surveys provide an overview of the existing situation. Currently, PC is largely focused on the needs of cancer patients and this is a legacy issue for professionals and systems. Communities however recognize suffering and do not distinguish between medical diagnoses. The development of NpC as a subspecialty of neurology allows neurologists everywhere to become primary palliative care providers for their own patients. It is also necessary to integrate neurology with existing palliative care services. There is much that can be done to improve NpC provision even within the limits that bound every jurisdiction and trial evidence is emerging to inform this practice. This chapter is a survey of the challenges and the potential.
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Affiliation(s)
- Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India.
| | - Stefan Lorenzl
- Institute of Palliative Care and Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
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60
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Risco JR, Kelly AG, Holloway RG. Prognostication in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:175-193. [PMID: 36055715 DOI: 10.1016/b978-0-323-85029-2.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.
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Affiliation(s)
- Jorge R Risco
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, United States.
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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62
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Brennan F, Gardiner MD, Narasimhan M. The neuropalliative multidisciplinary team-Members and their roles. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:33-59. [PMID: 36055719 DOI: 10.1016/b978-0-323-85029-2.00010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurodegenerative conditions are prominent contributors to both morbidity and mortality worldwide. They pose a significant challenge to health professionals, health systems, and the often unpaid, untrained family members and carers. The many and varied challenges encountered are best managed by a multidisciplinary neuropalliative team, as it is impossible for a single clinician to possess and deliver the wide range of skills and services required to optimally care for these patients. This chapter discusses the assembly, maintenance, and care of such a team, as well as potential difficulties and solutions in domains such as funding, training, geographical remoteness, as well as the potential lack of awareness and acceptance by colleagues. A comprehensive description of the role of all possible team members is discussed. The chapter outlines the concept, content, and potential benefits of a multidisciplinary team in neuropalliative care. Its thesis is twofold: that multidisciplinary care is vital and, second, that the sum of the whole of a team can be greater than the individual parts with respect to organization, planning, experience, and creativity of approach. With all these factors considered, and implemented wherever possible, we may all move closer to optimizing the comfort and care of our shared neuropalliative patients.
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Affiliation(s)
- Frank Brennan
- Departments of Palliative and Rehabilitation Medicine, Calvary and St George Hospitals, Sydney, NSW, Australia; The Faculty of Medicine, St George Clinical School, The University of New South Wales, Sydney, NSW, Australia.
| | - Matthew D Gardiner
- Departments of Palliative and Rehabilitation Medicine, Calvary and St George Hospitals, Sydney, NSW, Australia; The Faculty of Medicine, St George Clinical School, The University of New South Wales, Sydney, NSW, Australia
| | - Manisha Narasimhan
- School of Psychology and Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia; Department of Neurology, Sutherland Hospital, Sydney, NSW, Australia
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63
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Abstract
Primary palliative care is a fundamental aspect of high-quality care for patients with a serious illness such as dementia. The clinician caring for a patient and family suffering with dementia can provide primary palliative care in numerous ways. Perhaps the most important aspects are high quality communication while sharing a diagnosis, counseling the patient through progression of illness and prognostication, and referral to hospice when appropriate. COVID-19 presents additional risks of intensive care requirement and mortality which we must help patients and families navigate. Throughout all of these discussions, the astute clinician must monitor the patient's decision making capacity and balance respect for autonomy with protection against uninformed consent. Excellent primary palliative care also involves discussion of deprescribing medications of uncertain benefit such as long term use of cholinesterase inhibitors and memantine and being vigilant in the monitoring of pain with its relationship to behavioral disturbance in patients with dementia. Clinicians should follow a standardized approach to pain management in this vulnerable population. Caregiver burden is high for patients with dementia and comprehensive care should also address this burden and implement reduction strategies. When these aspects of care are particularly complex or initial managements strategies fall short, palliative care specialists can be an important additional resource not only for the patient and family, but for the care team struggling to guide the way through a disease with innumerable challenges.
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Affiliation(s)
- Neal Weisbrod
- Department of Neurology, University of Florida, 1505 SW Archer, Gainesville, FL, 32608, USA.
- Department of Medicine Division of Palliative Care, University of Florida, 1505 SW Archer, Gainesville, FL, 32608, USA.
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64
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Cook T, Arnold R, Jeong K, Childers J. Opinion & Special Article: Next Steps in Palliative Care Education for Neurology Residents. Neurology 2021; 97:1134-1137. [PMID: 34610988 DOI: 10.1212/wnl.0000000000012911] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Many neurologic diseases are life limiting and markedly impair patients' quality of life. Growing recommendations in the field recommend that neurologists have primary skills in palliative medicine that will allow them to manage symptoms and discuss end-of-life decisions with patients and families. Previous work has shown that formal palliative care training in neurology residencies is very limited. In this article, we briefly describe a national survey of neurology residents where we assess both the quantity and quality of the teaching they receive in end-of-life care as compared to a common and an uncommon neurologic condition. Based on the gaps we identified, as well as previous studies and recommendations in neuropalliative care, we provide 9 recommendations to help neurology residency programs improve their teaching of primary neuropalliative care skills.
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Affiliation(s)
- Tara Cook
- From the University of Pittsburgh, PA
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65
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Takacs SM, Comer AR. Documentation of advance care planning forms in patients with amyotrophic lateral sclerosis. Muscle Nerve 2021; 65:187-192. [PMID: 34787317 DOI: 10.1002/mus.27462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION/AIMS Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized by progressive weakness. Survival is typically only a few years from symptom onset. The often-predictable disease course creates opportunities to complete advance care planning (ACP) forms. The Physician Orders for Life-Sustaining Treatment (POLST) is a broadly used ACP paradigm to communicate end-of-life wishes but has not been well-studied in the ALS population. METHODS In this retrospective chart review study, patients diagnosed with ALS seen between 2014 and 2018 at an academic ALS center were identified. Demographic information, clinical characteristics, and ACP data were collected. RESULTS Of 513 patients identified, 30% had an ACP document. POLST forms were competed in 16.6% of patients with 73.8% of forms signed by a neurologist. Only 5.1% of patients saw a palliative care physician. Palliative care consultation was associated with having an POLST on file (P < .001). Patients with completed POLST forms were significantly more likely to have been seen in clinic more frequently (P < .001) and have a lower ALS Functional Rating Scale-Revised score on last visit (P = .005). DISCUSSION Less than one third of patients with ALS completed an ACP document, and only a small percentage completed POLST forms. The data suggest a need for greater documentation of goals of care in the ALS population.
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Affiliation(s)
- Sara M Takacs
- Department of Neurology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Amber R Comer
- Department of Health Sciences, Indiana University School of Health and Human Sciences, Indianapolis, Indiana, USA
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66
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Kluger BM, Quill TE. Advancing neuropalliative care. Lancet Neurol 2021; 20:885. [PMID: 34687625 DOI: 10.1016/s1474-4422(21)00326-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Benzi M Kluger
- Departments of Neurology and Medicine, University of Rochester Medical Center, Rochester, NY 14618, USA.
| | - Timothy E Quill
- Department of Palliative Care and Medicine, University of Rochester Medical Center, Rochester, NY 14618, USA
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Abstract
BACKGROUND Parkinson's disease is a progressive neurodegenerative disorder that negatively impacts the lives of affected people. The therapeutic benefits of treatment only decrease going forward from the time of diagnosis. Motor and non-motor symptoms alike create a heavy burden for patients and those involved in their care. Palliative care is utilized for patients with serious illnesses and when integrated into patients with Parkinson's disease, improves quality of life by addressing symptoms of discomfort, which ultimately reduces symptom burden to patients and alleviates caregiver stress. OBJECTIVE This review aims to assess the efficacy of palliative care in the management of Parkinson's disease by exploring the benefits of palliative care integration throughout multiple relevant themes to demonstrate the optimal care delivery. METHODS Comprehensive searches on the role of palliative care in Parkinson's disease patients within MEDLINE, PUBMED, CINAHL, CENTRAL, PsycINFO, Embase, and BioMed Central, considering publications between March 2010 - February 2020 were performed. A grey literature search was also performed for additional information. RESULTS Analysis of various existing literature has demonstrated promise in timely palliative care integration for patients with Parkinson's disease, which has shown improvement in the quality of life of Parkinson's disease patients. It also strives to alleviate caregivers' stress and improve their quality of life, although insufficient research exists to support this. Palliative care in Parkinson's disease is a growing area of interest, evidently demonstrating the potential to expand among the current approaches. CONCLUSION Understanding the connections between the themes surrounding palliative care is crucial for successful integration in Parkinson's disease management. It is determined that integration of palliative care in patients with Parkinson's disease help to not only improve patients' experiences but also their caregiver's experiences throughout the disease trajectory. Further research should be conducted to address how palliative care will focus on alleviating caregiver burden and establish specific prognostication tools for Parkinson's disease patients.
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Affiliation(s)
- Helen Senderovich
- Department of Family and Community Medicine, Division of Palliative Care, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, Baycrest, Toronto, Canada
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Abstract
Many childhood neurologic conditions are first diagnosed in the perinatal period and shorten or seriously alter the lives of affected infants. Neonatal neuropalliative care incorporates core practices and teachings of both neurology and palliative care and is directed toward patients and families affected by serious neurologic conditions in the antenatal and immediate newborn period. This review outlines key considerations for neurologists hoping to provide a neuropalliative care approach antenatally, in the neonatal intensive care unit, and around hospital discharge. We explore 4 core domains of neuropalliative care: (1) family-centered communication, (2) prognostication, (3) decision making, and (4) pain and symptom management. We address special considerations in care at the end of life and in varied cultural and practice contexts.
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Affiliation(s)
- Sharla Rent
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Margarita Bidegain
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Margaret H. Bost
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Chi Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Monica E. Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
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Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
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70
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Creutzfeldt CJ. Palliative Care and Shared Decision Making in the Neurocritical Care Unit. ACTA ACUST UNITED AC 2021; 27:1430-1443. [PMID: 34618767 DOI: 10.1212/con.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the evidence on integrating palliative care into the care of patients with various types of serious neurologic illness, emphasizes the importance of palliative care in the neurocritical care unit, and suggests tools for clinicians to improve their communication skills and decision making. RECENT FINDINGS Palliative care is a holistic approach to medical care that aims to relieve physical, psychological, social, and spiritual suffering. It is both a medical specialty as young as neurocritical care itself and an approach to patient care by all clinicians who manage patients with serious illness. Patients presenting to the neurocritical care unit and their families have unique palliative care needs that challenge communication and shared decision making. SUMMARY Palliative care, effective communication, and shared decision making require a set of core skills that all neurology clinicians should master.
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Blackstone EC, Ford PJ, Sankary LR. Clarity on Palliative Neurosurgery: A Neuroethics Perspective. World Neurosurg 2021; 156:56-58. [PMID: 34506982 DOI: 10.1016/j.wneu.2021.08.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Eric C Blackstone
- Department of Bioethics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Paul J Ford
- Neuroethics Program, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Lauren R Sankary
- Department of Bioethics, Case Western Reserve University, Cleveland, Ohio, USA; Neuroethics Program, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Levy SA, Pedowitz E, Stein LK, Dhamoon MS. Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data. J Stroke Cerebrovasc Dis 2021; 30:106008. [PMID: 34330019 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022] Open
Abstract
Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.
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Affiliation(s)
- Sarah A Levy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Elizabeth Pedowitz
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, United States.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
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73
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Macchi ZA, Ayele R, Dini M, Lamira J, Katz M, Pantilat SZ, Jones J, Kluger BM. Lessons from the COVID-19 pandemic for improving outpatient neuropalliative care: A qualitative study of patient and caregiver perspectives. Palliat Med 2021; 35:1258-1266. [PMID: 34006157 PMCID: PMC9447864 DOI: 10.1177/02692163211017383] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND COVID-19 has impacted persons with serious illness, including those with chronic, neurodegenerative conditions. While there are several reports on COVID-19's impact on inpatient palliative care, literature is limited about the impact on outpatient care which may be more relevant for these patients. AIM To generate a person-centered description of the impact of COVID-19 from the perspectives of patients living with neurodegenerative disease and caregivers to improve outpatient palliative care delivery. DESIGN This qualitative study used rapid analysis via matrix design to identify emergent themes related to participant perspectives on the challenges of COVID-19. Data sources included semi-structured interviews, open-ended survey responses, medical record documentation and participant-researcher communications. SETTING/PARTICIPANTS Data was collected from 108 patients with Parkinson's disease, Alzheimer's disease or related disorders and 90 caregivers enrolled in a multicenter, clinical trial of community-based, outpatient palliative care between March 20, 2020 and August 8, 2020 (NCT03076671). RESULTS Four main themes emerged: (1) disruptions to delivery of healthcare and other supportive services; (2) increased symptomatic and psychosocial needs; (3) increased caregiver burden; (4) limitations of telecommunications when compared to in-person contact. We observed that these themes interacted and intersected. CONCLUSIONS Patients and caregivers have unmet care needs because of the pandemic, exacerbated by social isolation. While telemedicine has helped improve access to healthcare, patients and caregivers perceive clear limitations compared to in-person services. Changes in society and healthcare delivery in response to COVID-19 highlight ongoing and novel gaps that must be addressed to optimize future outpatient palliative care for neurologic illness.
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Affiliation(s)
- Zachary A Macchi
- Department of Neurology, University of Colorado Anschutz, Aurora, CO, USA.,Department of Internal Medicine, University of Colorado Anschutz, Aurora, CO, USA
| | - Roman Ayele
- College of Nursing, University of Colorado Anschutz, Aurora, CO, USA
| | - Megan Dini
- Department of Neurology, University of Colorado Anschutz, Aurora, CO, USA
| | - Jensine Lamira
- Department of Cell & Developmental Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maya Katz
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Steven Z Pantilat
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jacqueline Jones
- College of Nursing, University of Colorado Anschutz, Aurora, CO, USA
| | - Benzi M Kluger
- Departments of Neurology and Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Sokol LL, Lum HD, Creutzfeldt CJ, Cella D, Forlizzi J, Cerf M, Hauser JM, Kluger BM. Meaning and Dignity Therapies for Psychoneurology in Neuropalliative Care: A Vision for the Future. J Palliat Med 2021; 23:1155-1156. [PMID: 32877285 DOI: 10.1089/jpm.2020.0129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Leonard L Sokol
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,McGaw Bioethics Scholars Program, Center for Bioethics and Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Eastern Colorado VA Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | | | - David Cella
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jodi Forlizzi
- Human-Computer Interaction Institute, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Moran Cerf
- Kellogg School of Management, Northwestern University, Evanston, Illinois, USA
| | - Joshua M Hauser
- Center for Bioethics and Medical Humanities, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Section of Palliative Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Palliative Care Service, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Benzi M Kluger
- Departments of Neurology and Medicine, University of Rochester Medical Center, Rochester, New York, USA
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Rhee JY, Brizzi K. Palliative Care for Polio and Postpolio Syndrome. Phys Med Rehabil Clin N Am 2021; 32:569-579. [PMID: 34175015 DOI: 10.1016/j.pmr.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Palliative care is a team-based approach focusing on relief of physical, psychosocial, and existential distress and communication about serious illness. Patients with poliomyelitis and postpolio syndrome are at risk for contractures and can benefit from involvement of physical and occupational therapy. Hypersialorrhea can be treated with anticholinergic medications, botox, or radiation. Patients with dyspnea may require noninvasive positive pressure ventilation ± opioids or benzodiazepines. Constipation is often due to autonomic dysfunction and decreased mobility. There is a higher burden of anxiety. Early conversations about patients' goals and values as it relates to their health may help frame future decision-making.
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Affiliation(s)
- John Y Rhee
- Wang Ambulatory Care Center, Suite 835, 15 Parkman Street, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kate Brizzi
- Wang Ambulatory Care Center, Suite 835, 15 Parkman Street, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, MA, USA.
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76
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Mainali S, Darsie ME. Neurologic and Neuroscientific Evidence in Aged COVID-19 Patients. Front Aging Neurosci 2021; 13:648662. [PMID: 33833676 PMCID: PMC8021699 DOI: 10.3389/fnagi.2021.648662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/23/2021] [Indexed: 12/20/2022] Open
Abstract
The COVID-19 pandemic continues to prevail as a catastrophic wave infecting over 111 million people globally, claiming 2. 4 million lives to date. Aged individuals are particularly vulnerable to this disease due to their fraility, immune dysfunction, and higher rates of medical comorbidities, among other causes. Apart from the primary respiratory illness, this virus is known to cause multi-organ dysfunction including renal, cardiac, and neurologic injuries, particularly in the critically-ill cohorts. Elderly patients 65 years of age or older are known to have more severe systemic disease and higher rates of neurologic complications. Morbidity and mortality is very high in the elderly population with 6–930 times higher likelihood of death compared to younger cohorts, with the highest risk in elderly patients ≥85 years and especially those with medical comorbidities such as hypertension, diabetes, heart disease, and underlying respiratory illness. Commonly reported neurologic dysfunctions of COVID-19 include headache, fatigue, dizziness, and confusion. Elderly patients may manifest atypical presentations like fall or postural instability. Other important neurologic dysfunctions in the elderly include cerebrovascular diseases, cognitive impairment, and neuropsychiatric illnesses. Elderly patients with preexisting neurologic diseases are susceptibility to severe COVID-19 infection and higher rates of mortality. Treatment of neurologic dysfunction of COVID-19 is based on existing practice standards of specific neurologic condition in conjunction with systemic treatment of the viral illness. The physical, emotional, psychologic, and financial implications of COVID-19 pandemic have been severe. Long-term data are still needed to understand the lasting effects of this devastating pandemic.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Marin E Darsie
- Department of Emergency Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, United States
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Abstract
PURPOSE OF REVIEW This review summarizes the current state of evidence for palliative care (PC) in movement disorders, describes the application of PC to clinical practice, and suggests future research directions. RECENT FINDINGS PC needs are common in persons living with movement disorders and their families from the time of diagnosis through end-of-life and contribute to quality of life. Early advance care planning is preferred by patients, impacts outcomes and is promoted by PC frameworks. Systematic assessment of non-motor symptoms, psychosocial needs and spiritual/existential distress may address gaps in current models of care. Several complementary and emerging models of PC may be utilized to meet the needs of this population. A PC approach may identify and improve important patient and caregiver-centered outcomes. As a relatively new application of PC, there is a need for research to adapt, develop and implement approaches to meet the unique needs of this population.
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Affiliation(s)
- Zachary A Macchi
- Department of Neurology, University of Colorado, Aurora, CO Building 400, Mail Stop F429, 12469 E 17th Place, Aurora, CO, 80045, USA.
| | - Christopher G Tarolli
- Department of Neurology, University of Rochester, Rochester, NY, USA
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
| | - Benzi M Kluger
- Department of Neurology, University of Rochester, Rochester, NY, USA
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
- Department of Medicine, Palliative Care Division, University of Rochester, Rochester, NY, USA
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78
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Kluger BM, Drees C, Wodushek TR, Frey L, Strom L, Brown MG, Bainbridge JL, Fischer SN, Shrestha A, Spitz M. Would people living with epilepsy benefit from palliative care? Epilepsy Behav 2021; 114:107618. [PMID: 33246892 PMCID: PMC9326903 DOI: 10.1016/j.yebeh.2020.107618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/30/2022]
Abstract
Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.
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Affiliation(s)
- Benzi M Kluger
- Departments of Neurology and Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Cornelia Drees
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Thomas R Wodushek
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lauren Frey
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura Strom
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mesha-Gay Brown
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jacquelyn L Bainbridge
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah N Fischer
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Archana Shrestha
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark Spitz
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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79
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Forst DA. Palliative and Supportive Care in Neuro-oncology. ACTA ACUST UNITED AC 2020; 26:1673-1685. [PMID: 33273177 DOI: 10.1212/con.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the supportive care needs of patients with primary brain tumors and their caregivers, outlines the management of selected common symptoms of patients with brain tumors, and describes challenges and opportunities in providing palliative care for this population. RECENT FINDINGS Patients with primary malignant brain tumors generally have a poor prognosis and experience progressive neurologic decline and significant physical and psychological symptoms. Management of these symptoms, including fatigue, mood disorders, and the manifestations of cerebral edema, can be challenging. Caregivers for these patients have high rates of psychological distress and report significant caregiving burden. Although the benefit of early palliative care for patients with other advanced solid tumors is well established, our understanding of the role of palliative care in neuro-oncology is incomplete, and thus palliative care and hospice services remain underutilized. SUMMARY Patients with brain tumors and their caregivers have significant supportive care needs, which often differ from the needs of patients with cancers outside of the nervous system. Clinicians face challenges associated with managing patients' symptoms and adequately facilitating prognostic understanding and decision making. Palliative care and hospice services may offer important benefits for this population.
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80
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Ben-Zacharia AB, Bethoux FA, Volandes A. Self-Perceived Knowledge and Comfort Discussing Palliative Care and End-of-Life Issues among Professionals Managing Neuroinflammatory Diseases. J Palliat Med 2020; 24:725-735. [PMID: 33064605 DOI: 10.1089/jpm.2020.0268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The growing trend in providing palliative care and end-of-life services has dictated that healthcare providers be adequately trained to care for people with serious illnesses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). These progressive inflammatory diseases lead to physical, cognitive and emotional deficits and have exceptionally high care demands leading to high levels of distress. Because the impact on the delivery of patient care is influenced by the specialists' knowledge and comfort discussing end-of-life issues, it is concerning that interventions to address unmet palliative care needs in MS and NMOSD rarely include clinician-patient dyads. Objectives: To evaluate the neurology clinicians' knowledge and level of comfort discussing palliative care and end-of-life issues. Design: A cross sectional survey was conducted. The statistical analyses included frequencies, chi square statistics and logistic regression. Setting/Subjects: 414 MS specialists answered an online anonymous survey. The survey was conducted using email distributions to MS professionals through the Consortium of MS Centers (CMSC), the International Organization of MS Nurses (IOMSN) and the UK Nurses' MS Organization. Measurement: The "End of Life Professional Caregiver Survey" (EPCS) was used to collect data. Results: The majority of the multidisciplinary professionals were female, white, nurses, and older than 40 years of age. 41% had their own advance directives and 57.6% had end-of-life basic training. There was a statistically significant association between end-of-life training or having advance directives and comfort discussing palliative care and end of life issues. Professionals that had basic end-of-life training and their own advance directives had higher comfort discussing code status, specific end-of-life issues, and advance directive planning. Conclusions: Basic end-of-life training and having advance directives among MS professionals were associated with better communication of palliative care and end-of-life domains with patients and their care partners.
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Affiliation(s)
- Aliza B Ben-Zacharia
- Hunter Bellevue School of Nursing, The Mount Sinai Beth Israel Phillips School of Nursing, New York, New York, USA
| | - Francois A Bethoux
- Department of Rehabilitation Services, Cleveland Clinic Mellen Center, Cleveland, Ohio, USA
| | - Angelo Volandes
- ACP Decisions, Waban, Massachusetts, USA.,Palliative Care, Harvard School of Medicine, Boston, Massachusetts, USA
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Kluger BM, Vaughan CL, Robinson MT, Creutzfeldt C, Subramanian I, Holloway RG. Neuropalliative care essentials for the COVID-19 crisis. Neurology 2020; 95:394-398. [PMID: 32591476 PMCID: PMC7538223 DOI: 10.1212/wnl.0000000000010211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/16/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Benzi M Kluger
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA.
| | - Christina L Vaughan
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA
| | - Maisha T Robinson
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA
| | - Claire Creutzfeldt
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA
| | - Indu Subramanian
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA
| | - Robert G Holloway
- From the Departments of Neurology and Medicine (B.M.K. and R.G.H.), University of Rochester Medical Center, NY; Departments of Neurology and Medicine (C.L.V.), University of Colorado Anschutz Medical Campus, Aurora; Departments of Neurology and Family Medicine (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.C.), University of Washington Harborview Medical Center, Seattle; and Department of Neurology (I.S.), Geffen School of Medicine, UCLA, and West LA Veterans Affairs Medical Center, CA
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Nair KPS, Chandler B, Lee M, Oliver D, Sansam K, King L, Paisley S, Sutton A, Cantrell A. Rehabilitation medicine in palliative care of chronic neurological conditions. BMJ Support Palliat Care 2020; 13:154-160. [DOI: 10.1136/bmjspcare-2020-002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 11/03/2022]
Abstract
BackgroundPeople living with long-term neurological conditions (LTNC) often require palliative care. Rehabilitation medicine specialists often coordinate the long-term care of these patients.ObjectiveThe aim of the present review was to undertake systematic literature searches to identify the evidence on palliative care for people with LTNC to guide rehabilitation medicine specialists caring for these patients in the UK.MethodsWe searched for evidence for (1) discussion of end of life, (2) planning for end-of-life care, (3) brief specialist palliative care interventions, (4) support for family and carers, (5) training of rehabilitation medicine specialists in palliative care, and (6) commissioning of services. The databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database and Health Technology Assessment Database. Evidence was assimilated using a simplified version of the Grading of Recommendations Assessment, Development and Evaluation method.ResultsWe identified 2961 records through database searching for neurological conditions and 1261 additional records through database searches for specific symptoms. We removed duplicate records and conference presentations. We screened 3234 titles and identified 330 potentially relevant abstracts. After reading the abstracts we selected 34 studies for inclusion in the evidence synthesis.ConclusionsFrom the evidence reviewed we would like to recommend that we move forward by establishing a closer working relationship with specialists in palliative care and rehabilitation medicine and explore the implications for cross-specialty training.
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Affiliation(s)
- Kate T Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston
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84
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Harrison KL, Allison TA, Garrett SB, Thompson N, Sudore RL, Ritchie CS. Hospice Staff Perspectives on Caring for People with Dementia: A Multisite, Multistakeholder Study. J Palliat Med 2020; 23:1013-1020. [PMID: 32130076 PMCID: PMC7404831 DOI: 10.1089/jpm.2019.0565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 01/03/2023] Open
Abstract
Background: In the United States, 45% of people enrolled in hospice have dementia. We know little about how hospice professionals facilitate preference-aligned end-of-life care for people with dementia (PWD) and their families. Objective: To examine hospice stakeholders' perspectives on caring for PWD and their families. Design: Multisite qualitative study using semi-structured interviews with interdisciplinary hospice clinicians, leaders, and administrators. The interdisciplinary team used the constant comparative method to identify, code, and characterize relevant themes. Setting/participants: Four geographically distinct nonprofit U.S. hospice organizations. Fifty-one hospice employees: 61% clinical staff, 25% executive leaders, and 14% administrators. Measurements: Interview domains included participants' practices of engaging patients/families in discussions of preferences for end-of-life care and professional opinions of changes over time. Cross-topic probes focused on delivering hospice care to PWD and their proxies/families. Results: Four themes regarding caring for PWD in hospice. (1) Dementia prevalence in hospice is increasing and some hospices are developing programs to accommodate specific needs. (2) Setting impacts discussions of preferences and care decisions. (3) Caring for PWD on hospice poses unique challenges caused by (i) perceptions that dementia is not terminal, (ii) a lack of advance care planning discussions before hospice admission, and (iii) proxy decision-makers who were inadequately prepared for their role. (4) Hospice regulatory and policy changes disproportionately impact PWD. Conclusions: Hospice professionals perceive increasing demand for, and multilevel challenges to, caring for PWD. Clinicians "upstream" from hospice may help by engaging patients and proxies in discussions of preferences for end-of-life care and providing anticipatory guidance.
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Affiliation(s)
- Krista L. Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Theresa A. Allison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sarah B. Garrett
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Nicole Thompson
- Osher Center for Integrative Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine S. Ritchie
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Campus for Jewish Living, San Francisco, California, USA
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85
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Oliver D, Borasio GD, Veronese S, Voltz R, Lorenzl S, Hepgul N. Current collaboration between palliative care and neurology: a survey of clinicians in Europe. BMJ Support Palliat Care 2020:bmjspcare-2020-002322. [PMID: 32651190 DOI: 10.1136/bmjspcare-2020-002322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The collaboration between palliative care and neurology has developed over the last 25 years and this study aimed to ascertain the collaboration between the specialties across Europe. METHODS This online survey aimed to look at collaboration across Europe, using the links of the European Association for Palliative Care and the European Academy of Neurology. RESULTS 298 people completed the survey-178 from palliative care and 120 from neurology from over 20 countries across Europe. They reported that there was good collaboration in the care for people with amyotrophic lateral sclerosis and cerebral tumours but less for other progressive neurological diseases. The collaboration included joint meetings and clinics and telephone contacts. All felt that the collaboration was helpful, particularly for maintaining quality of life, physical symptom management, psychological support and complex decision making, including ethical issues. DISCUSSION The study shows evidence for collaboration between palliative care and neurology, but with the need to develop this for all neurological illness, and there is a need for increased education of both areas.
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Affiliation(s)
- David Oliver
- Tizard Centre, University of Kent, Canterbury, Kent, UK
| | - Gian Domenico Borasio
- Service de soins palliatifs, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Stefan Lorenzl
- Institute of Nursing Sciences and Practice, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Nilay Hepgul
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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86
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Hwang DY, Knies AK, Mampre D, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L. Concerns of surrogate decision makers for patients with acute brain injury: A US population survey. Neurology 2020; 94:e2054-e2068. [PMID: 32341190 PMCID: PMC7282883 DOI: 10.1212/wnl.0000000000009406] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether groups of surrogates for patients with severe acute brain injury (SABI) with poor prognosis can be identified based on their prioritization of goals-of-care (GOC) decisional concerns, an online survey of 1,588 adults recruited via a probability-based panel representative of the US population was conducted. METHODS Participants acted as a surrogate for a GOC decision for a hypothetical patient with SABI and were randomized to 1 of 2 prognostic scenarios: the patient likely being left with a range of severe functional disability (SD) or remaining in a vegetative state (VS). Participants prioritized a list of 12 decisional concerns via best-worst scaling. Latent class analysis (LCA) was used to discover decisional groups. RESULTS The completion rate was 44.6%; data weighting was conducted to mitigate nonresponse bias. For 792 SD respondents, LCA revealed 4 groups. All groups shared concerns regarding respecting patient wishes and minimizing suffering. The 4 groups were otherwise distinguished by unique concerns that their members highlighted: an older adult remaining severely disabled (34.4%), family consensus (26.4%), doubt regarding prognostic accuracy (20.7%), and cost of long-term care (18.6%). For the 796 VS respondents, LCA revealed 5 groups. Four of the 5 groups had similar concern profiles to the 4 SD groups. The largest (29.0%) expressed the most prognostic doubt. An additional group (15.8%) prioritized religious concerns. CONCLUSIONS Although surrogate decision makers for patients with SABI are concerned with respecting patient wishes and minimizing suffering, certain groups highly prioritize other specific decisional factors. These data can help inform future interventions for supporting decision makers.
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Affiliation(s)
- David Y Hwang
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT.
| | - Andrea K Knies
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - David Mampre
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Stanislav Kolenikov
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Marci Schalk
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Heather Hammer
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Douglas B White
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Robert G Holloway
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Liana Fraenkel
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
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Patel R, Rhee PC. Team Approach: Multidisciplinary Perioperative Care in Upper-Extremity Reconstruction for Adults with Spasticity and Contractures. JBJS Rev 2020; 8:e0164. [DOI: 10.2106/jbjs.rvw.19.00164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Oliver D, de Visser M, Voltz R. Editorial: Palliative Care in Neurology. Front Neurol 2020; 10:1370. [PMID: 31998223 PMCID: PMC6970193 DOI: 10.3389/fneur.2019.01370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/11/2019] [Indexed: 12/01/2022] Open
Affiliation(s)
- David Oliver
- Tizard Centre, University of Kent, Canterbury, United Kingdom
| | | | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Köln, Germany
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Goyal T, Hasty BN, Bereknyei Merrell S, Gold CA. Education Research: Understanding barriers to goals of care communication for neurology trainees. Neurology 2019; 93:362-366. [DOI: 10.1212/wnl.0000000000007975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo describe the perspectives of neurology residents regarding barriers to effective goals of care discussions and to identify residents' current and desired educational strategies to improve goals of care communication.MethodsAll neurology residents at our institution were invited to voluntarily participate in focus groups. Residents were organized into 3 focus groups by year of training. Moderators asked residents open-ended questions about current goals of care communication practice and ideas for improving the frequency and effectiveness of goals of care discussions. All responses were audiorecorded, transcribed, and de-identified. Transcripts of the focus groups were independently read and coded by members of the research team. We performed thematic analysis to identify and systematize relationships across coded data.ResultsTwenty out of 29 neurology residents participated in the focus groups. We identified 3 overarching domains impeding goals of care communication: patient factors, resident factors, and systems factors. Residents proposed specific desired strategies to address these 3 domains with the goal of improving the frequency and efficacy of goals of care communication. The desired strategies included receiving feedback from patients and families, developing resident-focused educational opportunities through direct observation and coaching, and systems changes by documenting goals of care discussions.ConclusionsNeurology residents identify multiple barriers to effective goals of care communication and propose specific desired strategies for improvement. This detailed input from residents will be incorporated into future curricular interventions to improve confidence and skill in leading goals of care discussions.
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90
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Brizzi K, Paganoni S, Zehm A, De Marchi F, Berry JD. Integration of a palliative care specialist in an amyotrophic lateral sclerosis clinic: Observations from one center. Muscle Nerve 2019; 60:137-140. [PMID: 31172537 DOI: 10.1002/mus.26607] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/28/2019] [Accepted: 06/02/2019] [Indexed: 12/14/2022]
Abstract
Palliative care specialists can aid in the care of patients with amyotrophic lateral sclerosis (ALS). In this article, we describe our 1-year experience incorporating a palliative care specialist into the ALS multidisciplinary team. We describe our integration model, patient selection, and visit content. Of 500 total clinic patients, 74 (14.8%) were seen by the palliative care specialist in 1 year. Referral was most often triggered by advance care planning needs (91%). In the initial visit with the palliative care specialist, topics most frequently covered included goals of care (84%), anxiety/depression (35%), and medical decision-making about feeding tubes (27%) or tracheostomy (31%). Symptom management comprised a relatively small number of the visits, and duration of visits was limited by patient fatigue. Patients with complex goals of care may benefit from the input of a palliative care specialist, and unique integration models may help to facilitate care delivery. Muscle Nerve 60: 137-140, 2019.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, WACC 8, Suite 835, 15 Parkman Street, Boston, Massachusetts 02114, USA
| | - Sabrina Paganoni
- Healey Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April Zehm
- Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabiola De Marchi
- Healey Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Berry
- Healey Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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91
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Tuck KK, Tarolli CG. Palliative care and advance care planning in Parkinson disease. Neurology 2019; 92:1039-1040. [PMID: 31028128 DOI: 10.1212/wnl.0000000000007555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Keiran K Tuck
- From the Department of Neurology (K.K.T.), Legacy Health, Portland, OR; and the Department of Neurology (C.G.T.), University of Rochester Medical Center, NY.
| | - Christopher G Tarolli
- From the Department of Neurology (K.K.T.), Legacy Health, Portland, OR; and the Department of Neurology (C.G.T.), University of Rochester Medical Center, NY
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92
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Taylor BL, O'Riordan DL, Pantilat SZ, Creutzfeldt CJ. Inpatients with neurologic disease referred for palliative care consultation. Neurology 2019; 92:e1975-e1981. [PMID: 30918095 DOI: 10.1212/wnl.0000000000007364] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 01/03/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation. METHODS This prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer. RESULTS The most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital. CONCLUSIONS Patients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.
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Affiliation(s)
- Breana L Taylor
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco.
| | - David L O'Riordan
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
| | - Steven Z Pantilat
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
| | - Claire J Creutzfeldt
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
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Vishnevetsky A, Zapata del Mar C, Luis Cam J, Cornejo-Olivas M, Creutzfeldt CJ. Palliative Care: Perceptions, Experiences, and Attitudes in a Peruvian Neurologic Hospital. J Palliat Med 2019; 22:250-257. [PMID: 30526275 PMCID: PMC6391604 DOI: 10.1089/jpm.2018.0196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The development of palliative care in Peru remains limited, particularly for nononcological services, such as neurology. The goal of this study was to explore attitudes toward and knowledge about palliative and end-of-life care among patients, families, nurses, and doctors in a specialized neurological institute in Lima, Peru. MATERIALS AND METHODS We used a mixed methods approach consisting of 78 surveys and 21 qualitative, semistructured interviews that were recorded, transcribed, and analyzed using thematic analysis. RESULTS Surveys identified a substantial need for palliative care in the neurological institute (63% of doctors and 77% of nurses reported palliative care needs in >30% of their patients), and for training (82% of doctors and 69% of nurses reported inadequate palliative care education). The key themes emerging from qualitative interviews concerned transparency of communication about prognosis and end-of-life choices in neurological disease. Familiarity with advance directives was limited among both clinicians and families, and participants were divided about whether or not patients should be informed of serious diagnoses and prognoses, and who should inform them. Barriers to transparency in patient-physician communication included (1) expectation of cure; (2) physician's lack of training in communication and end-of-life care; (3) a paternalistic culture; and (4) the nature of neurological diseases. CONCLUSIONS Our study highlights opportunities to enhance palliative care and communication education for neurology providers and the public in Peru, a country that currently has no palliative care training program and no legal basis for advance directives.
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Affiliation(s)
- Anastasia Vishnevetsky
- Northern Pacific Global Health Consortium Fogarty Fellow, Lima, Peru
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Neurogenetics Research Center, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | | | - Juan Luis Cam
- Unidad de Cuidados Intensivos, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
| | - Mario Cornejo-Olivas
- Neurogenetics Research Center, Instituto Nacional de Ciencias Neurológicas, Lima, Peru
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Oliver DJ. Palliative care in motor neurone disease: where are we now? Palliat Care 2019; 12:1178224218813914. [PMID: 30718958 PMCID: PMC6348498 DOI: 10.1177/1178224218813914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022] Open
Abstract
Palliative care has a very important role in the care of patients with motor neurone disease and their families. There is increasing emphasis on the multidisciplinary assessment and support of patients within guidelines, supported by research. This includes the telling of the diagnosis, the assessment and management of symptoms, consideration of interventions, such as gastrostomy and ventilatory support, and care at the end of life. The aim of palliative care is to enable patients, and their families, to maintain as good a quality of life as possible and helping to ensure a peaceful death.
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Abstract
Neuropalliative care is a new and growing field within neurology that focuses on improving the quality of life of patients with serious neurologic illnesses. While specialty-level palliative care training is available to interested neurologists, all neurologists can strive to provide primary palliative care for their patients. In this review, we will describe the scope of neuropalliative care, define patient populations who may benefit from palliative care, and explore the communication and symptom management skills essential to palliative care delivery.
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Affiliation(s)
- K Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - C J Creutzfeldt
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Wang Ambulatory Care Center, Boston, Massachusetts
- Department of Neurology, Harborview Medical Center, Seattle, Washington
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