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Luijendijk HJ, de Bruin NC, Hulshof TA, Koolman X. Terminal illness and the increased mortality risk of conventional antipsychotics in observational studies: a systematic review. Pharmacoepidemiol Drug Saf 2015; 25:113-22. [PMID: 26601922 DOI: 10.1002/pds.3912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Numerous large observational studies have shown an increased risk of mortality in elderly users of conventional antipsychotics. Health authorities have warned against use of these drugs. However, terminal illness is a potentially strong confounder of the observational findings. So, the objective of this study was to systematically assess whether terminal illness may have biased the observational association between conventional antipsychotics and risk of mortality in elderly patients. METHODS Studies were searched in PubMed, CINAHL, Embase, the references of selected studies and articles referring to selected studies (Web of Science). Inclusion criteria were (i) observational studies that estimated (ii) the risk of all-cause mortality in (iii) new elderly users of (iv) conventional antipsychotics compared with atypical antipsychotics or no use. Two investigators assessed the characteristics of the exposure and reference groups, main results, measured confounders and methods used to adjust for unmeasured confounders. RESULTS We identified 21 studies. All studies were based on administrative medical and pharmaceutical databases. Sicker and older patients received conventional antipsychotics more often than new antipsychotics. The risk of dying was especially high in the first month of use, and when haloperidol was administered per injection or in high doses. Terminal illness was not measured in any study. Instrumental variables that were used were also confounded by terminal illness. CONCLUSIONS We conclude that terminal illness has not been adjusted for in observational studies that reported an increased risk of mortality risk in elderly users of conventional antipsychotics. As the validity of the evidence is questionable, so is the warning based on it.
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Affiliation(s)
- Hendrika J Luijendijk
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Geriatric Psychiatry, BAVO Europoort, Rotterdam, The Netherlands
| | - Niels C de Bruin
- Laurens Alzheimer's Care Research Center, Rotterdam, The Netherlands.,Novicare Geriatric Care Inc, Best, The Netherlands
| | - Tessa A Hulshof
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.,Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
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152
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de la Cruz M, Ransing V, Yennu S, Wu J, Liu D, Reddy A, Delgado-Guay M, Bruera E. The Frequency, Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit. Oncologist 2015; 20:1425-31. [PMID: 26417036 DOI: 10.1634/theoncologist.2015-0115] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/03/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency, characteristics, and outcomes of delirium in patients with advanced cancer admitted to an APCU. METHODS Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients' demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score ≥7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. RESULTS Of 556 patients in the APCU, 323 (58%) had a diagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admission and 94 (29%) developed delirium after admission to the APCU. Delirium reversed in 85 of 323 episodes (26%). Half of patients with delirium (n = 162) died. Patients with the diagnosis of delirium had a lower median overall survival than those without delirium. Patients who developed delirium after admission to the APCU had poorer survival (p ≤ .0001) and a lower rate of delirium reversal (p = .03) compared with those admitted with delirium. CONCLUSION More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival.
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Affiliation(s)
- Maxine de la Cruz
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Viraj Ransing
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennu
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marvin Delgado-Guay
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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153
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Hosie A, Lobb E, Agar M, Davidson PM, Chye R, Phillips J. Nurse perceptions of the Nursing Delirium Screening Scale in two palliative care inpatient units: a focus group study. J Clin Nurs 2015; 24:3276-85. [PMID: 26249026 DOI: 10.1111/jocn.12925] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2015] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To explore nurse perceptions of the feasibility of integrating the Nursing Delirium Screening Scale into practice within the inpatient palliative care setting. BACKGROUND Delirium occurs frequently in palliative care inpatient populations, yet is under-recognised. Exploring feasibility of delirium screening tools in this setting can provide insights into how recognition can be improved. DESIGN This was a qualitative study using a focus group methodology. METHOD Four semi-structured focus groups were conducted with 21 nurses working in two Australian palliative care units. Focus groups were digitally recorded and transcribed verbatim. Thematic content analysis was used to analyse the data. RESULTS Three major themes were identified: (1) Delirium screening using the Nursing Delirium Screening Scale is feasible, but then what? (2) Nuances, ambiguity and clinical complexity; and (3) Implementing structured processes requires firmer foundations. Themes describe how nurses perceived the Nursing Delirium Screening Scale to be an easy and brief screening tool which raised their awareness of delirium. They were largely willing to adopt it into practice, yet had uncertainty and misunderstandings of the tool specifically and delirium screening generally, application in a palliative care context, interventions for delirium and impact of screening on medical practice. CONCLUSION The Nursing Delirium Screening Scale is feasible for use in a palliative care inpatient setting, but requires investigation of its psychometric properties before routine use in this patient population. RELEVANCE TO CLINICAL PRACTICE Nurses require understanding of delirium, tailored guidance and a united approach with doctors to support their effective use of a delirium screening tool in the palliative care unit. Delirium practice change in this setting will also require nurses to become more active leaders and collaborators within their interdisciplinary teams.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,Faculty of Health, University of Technology Sydney, Darlinghurst, NSW, Australia
| | - Elizabeth Lobb
- Palliative Care Department, Calvary Health Care Sydney, Kogarah, NSW, Australia.,Cunningham Centre for Palliative Care, Sacred Heart Hospice, St Vincent's Health Network, Darlinghurst, NSW, Australia.,ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
| | - Meera Agar
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia.,Department of Palliative Care, Braeside Hospital, HammondCare, Prairiewood, NSW, Australia.,Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - Patricia M Davidson
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia.,School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Chye
- Cunningham Centre for Palliative Care, Sacred Heart Hospice, St Vincent's Health Network, Darlinghurst, NSW, Australia
| | - Jane Phillips
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia.,Centre for Cardiovascular and Chronic Care, University of Technology, Broadway, NSW, Australia
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154
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Affiliation(s)
- Augusto Caraceni
- Address: National Cancer Institute, Via venezian 1, 20133 Milano, Italy. Tel.: 39 02 23902792.
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155
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Abstract
Purpose of review Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care. Recent findings Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation. Summary Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.
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156
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Sampson EL, van der Steen JT, Pautex S, Svartzman P, Sacchi V, Van den Block L, Van Den Noortgate N. European palliative care guidelines: how well do they meet the needs of people with impaired cognition? BMJ Support Palliat Care 2015; 5:301-5. [PMID: 25869811 DOI: 10.1136/bmjspcare-2014-000813] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/11/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Numbers of people dying with cognitive impairment (intellectual disability (ID), dementia or delirium) are increasing. We aimed to examine a range of European national palliative care guidelines to determine if, and how well, pain detection and management for people dying with impaired cognition are covered. METHODS Questionnaires were sent to 14 country representatives of the European Pain and Impaired Cognition (PAIC) network who identified key national palliative care guidelines. Data was collected on guideline content: inclusion of advice on pain management, whether cognitively impaired populations were mentioned, assessment tools and management strategies recommended. Quality of guideline development was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. RESULTS 11 countries identified palliative care guidelines, 10 of which mentioned pain management in general. Of these, seven mentioned cognitive impairment (3 dementia, 2 ID and 4 delirium). Half of guidelines recommended the use of pain tools for people with cognitive impairment; recommended tools were not all validated for the target populations. Guidelines from the UK, the Netherlands and Finland included most information on pain management and detection in impaired cognition. Guidelines from Iceland, Norway and Spain scored most highly on AGREE rating in terms of developmental quality. CONCLUSIONS European national palliative care guidelines may not meet the needs of the growing population of people dying with cognitive impairment. New guidelines should consider suggesting the use of observational pain tools for people with cognitive impairment. Better recognition of their needs in palliative care guidelines may drive improvements in care.
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Affiliation(s)
- E L Sampson
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK Liaison Psychiatry, North Middlesex University Hospital, Barnet Enfield and Haringey Mental Health Trust, London, UK
| | - J T van der Steen
- Department of General Practice & Elderly Care Medicine, VU University Medical Center, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - S Pautex
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Switzerland
| | - P Svartzman
- Family Medicine Department, Ben-Gurion University of the Negev, Beersheba, Israel
| | - V Sacchi
- Peter Hodgkinson Centre, Lincoln County Hospital, Lincoln, UK
| | - L Van den Block
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Boland J, Currow DC, Wilcock A, Tieman J, Hussain JA, Pitsillides C, Abernethy AP, Johnson MJ. A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research. J Pain Symptom Manage 2015; 49:762-772.e5. [PMID: 25546286 DOI: 10.1016/j.jpainsymman.2014.09.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/31/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022]
Abstract
CONTEXT The challenges of palliative care clinical trial recruitment are well documented. OBJECTIVES The aim of the study was to review tested strategies to improve recruitment to trials of people with a range of conditions who may access palliative care services but are not explicitly stated to be "palliative." METHODS This was a systematic review with narrative description. The Cochrane, Embase, PubMed, PsycINFO, and CINAHL electronic databases were searched (English; January 2002 to February 2014) for quasi-experimental and randomized controlled trials (RCTs) testing the effect of recruitment strategies on accrual to clinical trials of people with organ failure and cancer. Titles, abstracts, and retrieved articles were screened by two researchers and categorized by recruitment challenge: 1) patients with reduced cognition, 2) those requiring emergency treatment, and 3) willingness of patients and clinical staff to contribute to trials. RESULTS Of 549 articles identified, 15 were included. Thirteen reported RCTs and two papers reported three quasi-experimental studies. Five were cluster RCTs of recruiting sites/institutions. One was a randomized cluster, crossover, feasibility study. Seven studies recruited patients with cancer. Others included patients with dementia, stroke, cardiovascular disease, diabetes, frail elderly, and bereaved carers. Some interventions improved recruitment: memory aid, contact before arrival, cluster consent, "opt out" consent. Others either reduced recruitment (formal mental capacity assessment) or made no difference (advance research directive; a variety of educational, supportive, and advertising interventions). CONCLUSION Successful strategies from other disciplines could be considered by palliative care researchers. Tailored, efficient, evidence-based strategies must be developed, acknowledging that strategies with face validity are not necessarily the most effective.
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Affiliation(s)
- Jason Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | - Jennifer Tieman
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | | | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, Hull, United Kingdom.
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158
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Reich M. Les troubles psychiatriques en soins palliatifs et en fin de vie. Presse Med 2015; 44:442-55. [DOI: 10.1016/j.lpm.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 10/23/2022] Open
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159
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Devery K, Rawlings D, Tieman J, Damarell R. Deathbed phenomena reported by patients in palliative care: clinical opportunities and responses. Int J Palliat Nurs 2015; 21:117-25. [DOI: 10.12968/ijpn.2015.21.3.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kim Devery
- Head of Discipline and Course Coordinator: Palliative Care, Senior Lecturer
| | | | - Jennifer Tieman
- Associate Professor, Associate Dean (Research), School of Health Sciences CareSearch Director
| | - Raechel Damarell
- Senior Liaison Librarian for Medicine, Nursing and Health Sciences, all at Flinders University, Adelaide, Australia
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160
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Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, Riba M. Management of delirium in palliative care: a review. Curr Psychiatry Rep 2015; 17:550. [PMID: 25663153 DOI: 10.1007/s11920-015-0550-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Delirium is a complex but common disorder in palliative care with a prevalence between 13 and 88 % but a particular frequency at the end of life (terminal delirium). By reviewing the most relevant studies (MEDLINE, EMBASE, PsycLit, PsycInfo, Cochrane Library), a correct assessment to make the diagnosis (e.g., DSM-5, delirium assessment tools), the identification of the possible etiological factors, and the application of multicomponent and integrated interventions were reported as the correct steps to effectively manage delirium in palliative care. In terms of medications, both conventional (e.g., haloperidol) and atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine, aripiprazole) were shown to be equally effective in the treatment of delirium. No recommendation was possible in palliative care regarding the use of other drugs (e.g., α-2 receptors agonists, psychostimulants, cholinesterase inhibitors, melatonergic drugs). Non-pharmacological interventions (e.g., behavioral and educational) were also shown to be important in the management of delirium. More research is necessary to clarify how to more thoroughly manage delirium in palliative care.
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Affiliation(s)
- Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Corso Giovecca 203, 44121, Ferrara, Italy,
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162
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Paddick SM, Kalaria RN, Mukaetova-Ladinska EB. The prevalence and clinical manifestations of delirium in sub-Saharan Africa: a systematic review with inferences. J Neurol Sci 2014; 348:6-17. [PMID: 25466692 DOI: 10.1016/j.jns.2014.10.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/30/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In high-income countries with ageing populations, delirium is most prevalent in older adults and in palliative and intensive care settings. The prevalence and aetiology of delirium are likely to differ in low income countries, including sub-Saharan Africa (SSA), due to different population demographics, disease burden and exposure to pathogens. We reviewed published literature relating to the prevalence, clinical features and underlying causes of delirium in SSA and compare this with that published in high-income countries in order to identify knowledge and clinical service gaps, and priorities for further research. METHODS We performed a narrative review by comprehensively searching the following databases: Medline, PsychInfo, Embase and PubMed. Studies published between January 1 1975 and December 31 2013 in all languages, including the terms 'delirium', 'acute brain syndrome', 'organic brain syndrome', or 'acute confusion' originating from SSA were included. In addition, reference lists of included articles and online databases of African medical literature were hand-searched. We also included case series and case reports due to paucity of published studies. RESULTS We identified a total of 46 relevant studies. Delirium was the main focus of only one cross-sectional study, whereas most included delirium in studies on neuropsychiatric conditions. Only two studies reported prevalence in older adults. Most studies reported very low (<2%) delirium prevalence, whereas delirium in psychiatric inpatient and outpatient settings was higher than expected (18.2%-29.9%). Descriptive studies of 'bouffee delirante' from psychiatry settings were often describing delirium. Infection and HIV seropositivity were common associations of delirium throughout these studies. There were no studies of intensive, critical or surgical care settings or of management strategies. CONCLUSIONS We currently know very little about the prevalence, presentation and aetiology of delirium in developing countries. This knowledge gap should be tackled with some urgency, in order to address questions of screening, diagnosis, prevention and management in this setting.
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Affiliation(s)
- S-M Paddick
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK; Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - R N Kalaria
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK.
| | - E B Mukaetova-Ladinska
- Institute for Ageing and Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, UK
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163
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Hosie A, Lobb E, Agar M, Davidson PM, Phillips J. Identifying the barriers and enablers to palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study. J Pain Symptom Manage 2014; 48:815-30. [PMID: 24726761 DOI: 10.1016/j.jpainsymman.2014.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/21/2014] [Accepted: 02/07/2014] [Indexed: 12/27/2022]
Abstract
CONTEXT Delirium is underrecognized by nurses, including those working in palliative care settings where the syndrome occurs frequently. Identifying contextual factors that support and/or hinder palliative care nurses' delirium recognition and assessment capabilities is crucial, to inform development of clinical practice and systems aimed at improving patients' delirium outcomes. OBJECTIVES The aim of the study was to identify nurses' perceptions of the barriers and enablers to recognizing and assessing delirium symptoms in palliative care inpatient settings. METHODS A series of semistructured interviews, guided by critical incident technique, were conducted with nurses working in Australian palliative care inpatient settings. A hypoactive delirium vignette prompted participants' recall of delirium and identification of the perceived factors (barriers and enablers) that impacted on their delirium recognition and assessment capabilities. Thematic content analysis was used to analyze the qualitative data. RESULTS Thirty participants from nine palliative care services provided insights into the barriers and enablers of delirium recognition and assessment in the inpatient setting that were categorized as patient and family, health professional, and system level factors. Analysis revealed five themes, each reflecting both identified barriers and current and/or potential enablers: 1) value in listening to patients and engaging families, 2) assessment is integrated with care delivery, 3) respecting and integrating nurses' observations, 4) addressing nurses' delirium knowledge needs, and 5) integrating delirium recognition and assessment processes. CONCLUSION Supporting the development of palliative care nursing delirium recognition and assessment practice requires attending to a range of barriers and enablers at the patient and family, health professional, and system levels.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia.
| | - Elizabeth Lobb
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Palliative Care Department, Calvary Health Care Sydney, Kogarah, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Meera Agar
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Prairiewood, New South Wales, Australia; Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Patricia M Davidson
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Faculty of Health, University of Technology, Broadway, New South Wales
| | - Jane Phillips
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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164
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The routine use of the Edmonton Classification System for Cancer Pain in an outpatient supportive care center. Palliat Support Care 2014; 13:1185-92. [DOI: 10.1017/s1478951514001205] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractObjective:There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and research studies. The Edmonton Classification System for Cancer Pain (ECS–CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of our study was to determine the relationship between negative ECS–CP features and some pain-related variables like pain intensity and opioid use. We also explored whether the number of negative ECS–CP features was associated with higher pain intensity.Method:The electronic charts of 100 patients at an outpatient supportive care clinic in a comprehensive cancer center were reviewed for variables like patient characteristics, initial ECS–CP assessment, morphine equivalent daily dose (MEDD), opioid rotation, Edmonton Symptom Assessment Score (ESAS), and use of adjuvant analgesics.Results:Some 91 of the 100 charts were eligible for analysis. The most common primary cancer type was gastrointestinal (22.1%). The median pain intensity was 6, and the median MEDD was 45 mg. Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p = 0.007) and median MEDD requirement (83 vs. 30, p = 0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p = 0.042). Incident pain was also associated with a trend toward higher pain intensity (6 vs. 5, p = 0.06). A higher number of negative ECS–CP features was associated with higher pain intensity (p = 0.01).Significance of Results:The ECS–CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with a higher MEDD. A higher sum of negative ECS–CP features was associated with higher pain intensity. Further studies will be needed to verify and explore these observations.
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165
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Hosie A, Agar M, Lobb E, Davidson PM, Phillips J. Palliative care nurses’ recognition and assessment of patients with delirium symptoms: A qualitative study using critical incident technique. Int J Nurs Stud 2014; 51:1353-65. [DOI: 10.1016/j.ijnurstu.2014.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/07/2014] [Accepted: 02/09/2014] [Indexed: 12/20/2022]
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166
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rainsford S, Rosenberg JP, Bullen T. Delirium in Advanced Cancer: Screening for the Incidence on Admission to an Inpatient Hospice Unit. J Palliat Med 2014; 17:1045-8. [DOI: 10.1089/jpm.2013.0646] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - John P. Rosenberg
- Formerly Calvary Centre for Palliative Care Research and the Australian Catholic University, Canberra, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Tracey Bullen
- Formerly Calvary Centre for Palliative Care Research and the Australian Catholic University, Canberra, Australia
- Institute of Child Protection Studies, Australian Catholic University, Canberra, Australia
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Bush SH, Kanji S, Pereira JL, Davis DHJ, Currow DC, Meagher D, Rabheru K, Wright D, Bruera E, Hartwick M, Gagnon PR, Gagnon B, Breitbart W, Regnier L, Lawlor PG. Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development. J Pain Symptom Manage 2014; 48:231-248. [PMID: 24480529 PMCID: PMC4081457 DOI: 10.1016/j.jpainsymman.2013.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Salmaan Kanji
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - José L Pereira
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Daniel H J Davis
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David C Currow
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Meagher
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Kiran Rabheru
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Wright
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Michael Hartwick
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Pierre R Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Bruno Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - William Breitbart
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Laura Regnier
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Peter G Lawlor
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Lawlor PG, Davis DHJ, Ansari M, Hosie A, Kanji S, Momoli F, Bush SH, Watanabe S, Currow DC, Gagnon B, Agar M, Bruera E, Meagher DJ, de Rooij SEJA, Adamis D, Caraceni A, Marchington K, Stewart DJ. An analytical framework for delirium research in palliative care settings: integrated epidemiologic, clinician-researcher, and knowledge user perspectives. J Pain Symptom Manage 2014; 48:159-175. [PMID: 24726762 PMCID: PMC4128755 DOI: 10.1016/j.jpainsymman.2013.12.245] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/24/2013] [Accepted: 12/09/2013] [Indexed: 12/30/2022]
Abstract
CONTEXT Delirium often presents difficult management challenges in the context of goals of care in palliative care settings. OBJECTIVES The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions. RESULTS Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very" or "extremely" important confirmed their priority. CONCLUSION Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings.
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Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel H J Davis
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Mohammed Ansari
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Sharon Watanabe
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David C Currow
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Bruno Gagnon
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Meera Agar
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Eduardo Bruera
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Meagher
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophia E J A de Rooij
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Dimitrios Adamis
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Augusto Caraceni
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Katie Marchington
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Stewart
- Division of Palliative Care (P.G.L.), Department of Medicine, Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute (P.G.L., S.H.B.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (P.G.L., S.K.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Knowledge Synthesis Group (M.An.), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Nursing (A.H.), University of Notre Dame, Sydney, New South Wales, Australia; The Ottawa Hospital (S.K.); Clinical Epidemiology Program (F.M.), Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (F.M.), University of Ottawa; Division of Palliative Care (S.H.B.), Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Symptom Control and Palliative Care (S.W.), Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada; Discipline of Palliative and Supportive Services (D.C.C., M.Ag.), Flinders University, Adelaide, South Australia, Australia; Département de médecine familiale et de médecine d'urgence (B.G.), Université Laval; Centre de recherche du CHU de Québec (B.G.), Québec City, Québec, Canada; South West Sydney Clinical School (M.Ag.), University of New South Wales; Department of Palliative Care (M.Ag.), Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia; The University of Texas M. D. Anderson Cancer Center (E.B.), Houston, Texas, USA; Graduate Entry Medical School (D.J.M.), University of Limerick, Limerick, Ireland; Academic Medical Centre (S.E.J.A.d.R.), University of Amsterdam, Amsterdam, The Netherlands; Research and Academic Institute of Athens (D.A.), Athens, Greece; Palliative Care, Pain Therapy and Rehabilitation Unit (A.C.), Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milan, Italy; Department of Palliative Care (K.M.), Bruyère Continuing Care; and Department of Medical Oncology (D.J.S.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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Sweet L, Adamis D, Meagher DJ, Davis D, Currow DC, Bush SH, Barnes C, Hartwick M, Agar M, Simon J, Breitbart W, MacDonald N, Lawlor PG. Ethical challenges and solutions regarding delirium studies in palliative care. J Pain Symptom Manage 2014; 48:259-71. [PMID: 24388124 PMCID: PMC4082407 DOI: 10.1016/j.jpainsymman.2013.07.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 07/11/2013] [Accepted: 07/17/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges. OBJECTIVES Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients. METHODS Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines. RESULTS Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models. CONCLUSION Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC.
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Affiliation(s)
- Lisa Sweet
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | | | - David J Meagher
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Cognitive Impairment Research Group, Department of Psychiatry, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Daniel Davis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - David C Currow
- Discipline of Palliative and Supportive Services, Bedford Park, South Australia, Australia; Flinders Centre for Clinical Change, Flinders University, Bedford Park, South Australia, Australia
| | - Shirley H Bush
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Palliative Care Unit, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Christopher Barnes
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Palliative Care Unit, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Michael Hartwick
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Critical Care Response Team, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Meera Agar
- Discipline of Palliative and Supportive Services, Bedford Park, South Australia, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jessica Simon
- Division of Palliative Medicine, Department of Oncology and Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; Department of Psychiatry, Weill Medical College of Cornell University, New York, New York, USA
| | - Neil MacDonald
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Peter G Lawlor
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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171
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Leonard MM, Nekolaichuk C, Meagher DJ, Barnes C, Gaudreau JD, Watanabe S, Agar M, Bush SH, Lawlor PG. Practical assessment of delirium in palliative care. J Pain Symptom Manage 2014; 48:176-90. [PMID: 24766745 DOI: 10.1016/j.jpainsymman.2013.10.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 10/25/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging. OBJECTIVES This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings. METHODS In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care. RESULTS Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes. CONCLUSION Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.
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Affiliation(s)
| | - Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Alberta, Canada; Tertiary Palliative Care Unit, Covenant Health, Grey Nuns Hospital, Edmonton, Alberta, Canada
| | - David J Meagher
- University of Limerick, Limerick, Ireland; Department of Adult Psychiatry, Limerick Regional Hospital, Limerick, Ireland
| | - Christopher Barnes
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-David Gaudreau
- Centre de recherche du CHU de Québec and Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada
| | - Sharon Watanabe
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Alberta, Canada; Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Meera Agar
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Shirley H Bush
- Bruyère and Ottawa Hospital Research Institutes, Ottawa, Ontario, Canada; Division of Palliative Care, Departments of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Bruyère and Ottawa Hospital Research Institutes, Ottawa, Ontario, Canada; Division of Palliative Care, Departments of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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172
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Bush SH, Leonard MM, Agar M, Spiller JA, Hosie A, Wright DK, Meagher DJ, Currow DC, Bruera E, Lawlor PG. End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase. J Pain Symptom Manage 2014; 48:215-30. [PMID: 24879997 DOI: 10.1016/j.jpainsymman.2014.05.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 01/21/2023]
Abstract
CONTEXT In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase. OBJECTIVES To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review. RESULTS The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan. CONCLUSION Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Maeve M Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Juliet A Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, United Kingdom
| | - Annmarie Hosie
- Faculty of Nursing, University of Notre Dame, Sydney, New South Wales, Australia
| | | | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - David C Currow
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Eduardo Bruera
- The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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173
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Rainsford S, Bullen T, Rosenberg J. Challenges of recruiting hospice inpatients with advanced cancer to research: Reflections on a delirium screening study. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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174
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Perrar KM, Golla H, Voltz R. [Pharmacological treatment of delirium in palliative care patients. A systematic literature review]. Schmerz 2014; 27:190-8. [PMID: 23503785 DOI: 10.1007/s00482-013-1293-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This systematic literature review aims to collect and analyse relevant clinical trials for the drug treatment of delirium in palliative care. The search was conducted including July 2012 in Medline (from 1966) and Embase (from 1974). The search retrieved 448 studies, of which 3 studies could be included in the analysis. Treatment with the antipsychotic drug haloperidol can be recommended, which is also true to a somewhat lower extent for the antipsychotics olanzapine and aripiprazole. Treatment with lorazepam only should be avoided. This literature analysis reflects the positive clinical experience, especially when using haloperidol. To confirm these recommendations, further substantial clinical studies are needed.The English full-text version of this article can be found at SpringerLink (under "Supplemental").
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Affiliation(s)
- K M Perrar
- Zentrum für Palliativmedizin, Uniklinik Köln, Kerpener Strasse 62, Köln, Germany.
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175
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Lassen CL, Abel R, Eichler L, Zausig YA, Graf BM, Wiese CHR. [Perioperative care of palliative patients by the anesthetist : medical, psychosocial and ethical challenges]. Anaesthesist 2013; 62:597-608. [PMID: 23836144 DOI: 10.1007/s00101-013-2198-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.
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Affiliation(s)
- C L Lassen
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
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