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Tennison JM, Fu JB, Hui D. Palliative Rehabilitation in Patients with Cancer: Definitions, Structures, Processes and Outcomes. Curr Oncol Rep 2024:10.1007/s11912-024-01585-8. [PMID: 39102013 DOI: 10.1007/s11912-024-01585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/06/2024]
Abstract
PURPOSEOF REVIEW This review examines the literature on palliative rehabilitation for patients with advanced cancer, focusing on definitions, structures, processes, and outcomes. RECENT FINDINGS Palliative cancer rehabilitation targets comfort and functional improvement for patients with limited rehabilitation potential across various settings. The palliative cancer rehabilitation team, typically led by a physician, coordinates symptom management and referrals to rehabilitation and other allied healthcare professionals as needed. The outcomes of palliative cancer rehabilitation varied widely by goals, settings, and interventions. Studies in hospice settings generally reported improved symptom control; inpatient rehabilitation had mixed functional outcomes; and outpatient palliative rehabilitation may contribute to enhanced functional and symptom outcomes, especially among patients with higher baseline function. Palliative cancer rehabilitation emphasizes a collaborative approach that integrates palliative care with rehabilitation interventions, aiming to enhance quality of life and address diverse patient needs. Further research and standardization are necessary to realize its full potential.
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Affiliation(s)
- Jegy M Tennison
- Department of Palliative, Rehabilitation, and Integrative Medicine, Section of Physical Medicine & Rehabilitation, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX, 77030, USA.
| | - Jack B Fu
- Department of Palliative, Rehabilitation, and Integrative Medicine, Section of Physical Medicine & Rehabilitation, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX, 77030, USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, Section of Palliative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Fingelkurts AA, Fingelkurts AA. Patients with Disorders of Consciousness: Are They Nonconscious, Unconscious, or Subconscious? Expanding the Discussion. Brain Sci 2023; 13:brainsci13050814. [PMID: 37239286 DOI: 10.3390/brainsci13050814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Unprecedented advancements in the diagnosis and treatment of patients with disorders of consciousness (DoC) have given rise to ethical questions about how to recognize and respect autonomy and a sense of agency of the personhood when those capacities are themselves disordered, as they typically are in patients with DoC. At the intersection of these questions rests the distinction between consciousness and unconsciousness. Indeed, evaluations of consciousness levels and capacity for recovery have a significant impact on decisions regarding whether to discontinue or prolong life-sustaining therapy for DoC patients. However, in the unconsciousness domain, there is the confusing array of terms that are regularly used interchangeably, making it quite challenging to comprehend what unconsciousness is and how it might be empirically grounded. In this opinion paper, we will provide a brief overview of the state of the field of unconsciousness and show how a rapidly evolving electroencephalogram (EEG) neuroimaging technique may offer empirical, theoretical, and practical tools to approach unconsciousness and to improve our ability to distinguish consciousness from unconsciousness and also nonconsciousness with greater precision, particularly in cases that are borderline (as is typical in patients with DoC). Furthermore, we will provide a clear description of three distant notions of (un)consciousness (unconsciousness, nonconsciousness, and subconsciousness) and discuss how they relate to the experiential selfhood which is essential for comprehending the moral significance of what makes life worth living.
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 PMCID: PMC8883802 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Edmond J. Safra Center for Ethics, Harvard
University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical
College, New York, NY 10021, USA
- Yale Law School, New Haven,
Connecticut 06511, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical
School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- School of Engineering and Carney Institute for Brain
Science, Brown University, Providence, RI 02906, USA
- VA RR&D Center for Neurorestoration and
Neurotechnology, Department of Veterans Affairs Medical Center,
Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Charlestown, MA 02129, USA
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Bilek AJ, Borodin O, Carmi L, Yakim A, Shtern M, Lerman Y. Older patients with active cancer have favorable inpatient rehabilitation outcomes. J Geriatr Oncol 2021; 12:799-807. [PMID: 33358109 DOI: 10.1016/j.jgo.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 12/06/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To investigate the characteristics and rehabilitation outcomes of older patients with active cancer (OPAC) undergoing post-acute inpatient rehabilitation (IR), and to evaluate which clinical factors are associated with poor rehabilitation outcomes. MATERIALS AND METHODS This is a retrospective study of patients aged ≥65 with active cancer undergoing IR following acute hospitalization at our tertiary hospital centre (N = 330). We collected data on patient, malignancy, and hospitalization characteristics, and IR outcomes including function, mobility, discharge destination, and mortality. Multivariate stepwise logistic regression was used to identify independent associations with the composite outcome of death within three months or discharge to long-term care (LTC). RESULTS Patient mean age was 80.1 ± 7.2 years. The most common malignancies were colon (30.9%) and hematologic (16.1%). Most patients were hospitalized urgently (64.8%) and underwent surgery (72.4%). From IR admission to discharge, patients ambulating independently increased from 14.0% to 52.0%. Discharge destination was to the community (80.4%), to LTC (7.6%), and transfer to an acute ward (7.2%), while 4.8% died during IR. One-year survival was 62.1%. The composite outcome was met by 24.8% of patients with multivariate logistic regression revealing independent associations (p < 0.05) with high baseline dependency, metastatic disease, low mobility score on IR admission, complications during acute care, and ≥ 75th percentile values for lactate dehydrogenase and alkaline phosphatase. CONCLUSION OPAC have favorable IR outcomes including high rate of community discharge, function and mobility gains, and lower mortality rates when compared with previously studied cancer rehabilitation populations. We identified several clinical markers associated with the composite outcome, which can guide post-acute discharge planning in patients with an unclear prognosis.
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Affiliation(s)
- Aaron Jason Bilek
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel.
| | - Oksana Borodin
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel; Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
| | - Liad Carmi
- Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
| | - Ariel Yakim
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel
| | - Michael Shtern
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel
| | - Yaffa Lerman
- Tel Aviv Sourasky Medical Center, Geriatric Division, 6 Weizmann Street, Tel Aviv 62431, Israel; Tel Aviv University, Faculty of Medicine, P.O. box 39040, Tel Aviv 69978, Israel
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Vega Peña NV, Riveros Dueñas M, Riscanevo AC. Scapulothoracic dissociation and blunt vertebral vascular injury: case report. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e504386. [PMID: 33402756 PMCID: PMC7744105 DOI: 10.25100/cm.v50i3.4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Case Description: A 24-year-old male suffers from a motor vehicle accident with penetrating neck trauma and concomitant closed left cervicothoracic trauma. Clinical Findings: High impact trauma causing hypovolemic shock, left zone I penetrating neck trauma, ischemia due to blunt trauma to the axillary vessels, and brachial plexus injury. Transection of the vertebral artery on angiotomography. Diagnosed with scapulothoracic dissociation and vertebral artery trauma. Treatment and outcome: Axillary arteriovenous reconstruction, fasciotomies, non-surgical approach of the vertebral artery trauma, and deferred treatment of the brachial plexus trauma were performed. Survival of the patient and his limb, with major neurologic sequelae Clinical Relevance: The case presented here is an example of scapulothoracic dissociation with associated trauma to the vertebral artery, injuries that are uncommon and associated with high morbidity and mortality. Early recognition of the injuries and a multidisciplinary approach for this complex case by surgical board reviews at various levels within the course of care were key determinants in the patient’s improved prognosis. This case report presents an analysis of the diagnostics, treatment, and course; considering in-hospital care and the decision-making process as determinants for the prognosis in a polytrauma patient.
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Vega Peña NV, Riveros Dueñas M, Riscanevo Bobadilla AC. Scapulothoracic dissociation and blunt vertebral vascular injury: case report. Colomb Med (Cali) 2020. [DOI: 10.25100/cm.v51i3.4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Case Description:
A 24-year-old male suffers from a motor vehicle accident with penetrating neck trauma and concomitant closed left cervicothoracic trauma.
Clinical Findings:
High impact trauma causing hypovolemic shock, left zone I penetrating neck trauma, ischemia due to blunt trauma to the axillary vessels, and brachial plexus injury. Transection of the vertebral artery on angiotomography. Diagnosed with scapulothoracic dissociation and vertebral artery trauma.
Treatment and outcome:
Axillary arteriovenous reconstruction, fasciotomies, non-surgical approach of the vertebral artery trauma, and deferred treatment of the brachial plexus trauma were performed. Survival of the patient and his limb, with major neurologic sequelae
Clinical Relevance:
The case presented here is an example of scapulothoracic dissociation with associated trauma to the vertebral artery, injuries that are uncommon and associated with high morbidity and mortality. Early recognition of the injuries and a multidisciplinary approach for this complex case by surgical board reviews at various levels within the course of care were key determinants in the patient’s improved prognosis. This case report presents an analysis of the diagnostics, treatment, and course; considering in-hospital care and the decision-making process as determinants for the prognosis in a polytrauma patient.
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Reilly JM, Gundersen AI, Silver JK, Tan CO, Knowlton SE. A Comparison of Functional Outcomes between Patients Admitted to Inpatient Rehabilitation after Initial Diagnosis Versus Recurrence of Glioblastoma Multiforme. PM R 2020; 12:975-983. [PMID: 32281244 DOI: 10.1002/pmrj.12379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prior studies of inpatient rehabilitation of patients with brain tumor demonstrate similar functional gains as compared to other rehabilitation populations. There are few studies specifically examining the rehabilitation of patients with glioblastoma. OBJECTIVE To compare functional outcomes between matched patients admitted to acute inpatient rehabilitation after initial diagnosis of glioblastoma (iGBM) and after diagnosis of recurrent glioblastoma (rGBM). DESIGN A retrospective, case-matched study using descriptive statistics compared demographic information and functional outcomes as designated by the Functional Independence Measure (FIM) score. SETTING A single, freestanding inpatient rehabilitation hospital. PATIENTS Over a 20-month period, 25 patients with iGBM were matched with 25 patients admitted to an inpatient rehabilitation facility with rGBM by the following criteria: (1) side of lesion (left/right hemisphere), (2) admission total FIM score within 10 points, (3) age within 10 years, and (4) gender. Nineteen of the 25 patients in each group were matched meeting all criteria, and 6 of the 25 patients were matched meeting three out of four criteria. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The primary outcome measures were differences in functional outcomes as measured by FIM scores. RESULTS There were no statistically significant differences (P < .05) between the groups in mean admission FIM scores, discharge FIM scores, FIM gains, and FIM efficiencies. There were no statistically significant differences in the development of complications during acute rehabilitation and transfer rate to acute care hospital. Sixty-four percent of patients in both groups were able to be discharged home. CONCLUSIONS This study demonstrated no statistically significant differences in functional outcomes between matched patients admitted with iGBM compared to rGBM. Further studies are indicated to examine the rehabilitation outcomes of patients with rGBM in inpatient rehabilitation.
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Affiliation(s)
- Julia M Reilly
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Alexandra I Gundersen
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Julie K Silver
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA.,Massachusetts General Hospital, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Can Ozan Tan
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, USA.,Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sasha E Knowlton
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Charlestown, MA, USA.,Massachusetts General Hospital, Boston, MA, USA
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