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Xia W, Ding J, Yan Y, Chen F, Yan M, Xu X. Effectiveness of Virtual Reality Technology in Symptom Management of Patients at the end of life: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2024; 25:105086. [PMID: 38880120 DOI: 10.1016/j.jamda.2024.105086] [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: 01/23/2024] [Revised: 05/07/2024] [Accepted: 05/07/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVES The objective of this review was to explore the effectiveness of virtual reality (VR) technology in symptom management of patients at the end of life. DESIGN This is a systematic review and meta-analysis, which has been registered on PROSPERO (CRD42022344679). SETTING AND PARTICIPANTS Patients at the end of life. METHODS PubMed, Embase, Web of Science, the Cochrane Library, JBI, EBSCO, CNKI, Wanfang, and SinoMed were searched from inception to July 31, 2023. Search terms included "virtual reality" and "end-of-life." Articles were screened according to the inclusion and exclusion criteria. The random effects model was used to calculate the standardized mean difference (SMD), and the fixed effects model was used to calculate the mean difference (MD). The Cochrane Risk of Bias Tool 2.0 and JBI Evaluation tool were used to assess the risk of bias. The I2 statistic was used to measure heterogeneity between studies. Forest plots were used for analysis. RESULTS A total of 234 patients at the end of life from 3 randomized controlled trials and 6 quasi-experimental studies were included. Compared with pre-VR intervention, the pain [standardized mean difference (SMD) -0.89, 95% CI -1.29 to -0.48, P < .05], shortness of breath [mean difference (MD) -0.98, 95% CI -0.98-0.51, P < .05], depression (MD -0.62, 95% CI -0.85 to -0.40, P < .05), and anxiety (SMD -0.93, 95% CI -1.50 to 0.36, P < .05) of patients at the end of life was significantly improved after VR intervention. However, there were no significant differences observed in tiredness, drowsiness, nausea, and lack of appetite. CONCLUSIONS AND IMPLICATIONS VR technology can be effective in improving pain, shortness of breath, depression, and anxiety in patients at the end of life. For tiredness, drowsiness, nausea, and lack of appetite, further research is required.
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Affiliation(s)
- Wanting Xia
- Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China; Xiangya Subcenter of JBI Evidence-Based Center, Changsha, Hunan, China
| | - JinFeng Ding
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China; Xiangya Subcenter of JBI Evidence-Based Center, Changsha, Hunan, China
| | - Yixia Yan
- Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, Hunan, China
| | - Furong Chen
- Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, Hunan, China
| | - Mengyao Yan
- Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China; Xiangya Subcenter of JBI Evidence-Based Center, Changsha, Hunan, China
| | - Xianghua Xu
- Department of Nursing, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, Hunan, China.
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2
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Binda F, Clari M, Nicolò G, Gambazza S, Sappa B, Bosco P, Laquintana D. Quality of dying in hospital general wards: a cross-sectional study about the end-of-life care. BMC Palliat Care 2021; 20:153. [PMID: 34641824 PMCID: PMC8507336 DOI: 10.1186/s12904-021-00862-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background In the last decade, access to national palliative care programs have improved, however a large proportion of patients continued to die in hospital, particularly within internal medicine wards. Objectives To describe treatments, symptoms and clinical management of adult patients at the end of their life and explore whether these differ according to expectation of death. Methods Single-centre cross-sectional study performed in the medical and surgical wards of a large tertiary-level university teaching hospital in the north of Italy. Data on nursing interventions and diagnostic procedure in proximity of death were collected after interviewing the nurse and the physician responsible for the patient. Relationship between nursing treatments delivered and patients’ characteristics, quality of dying and nurses’ expectation about death was summarized by means of multiple correspondence analysis (MCA). Results Few treatments were found statistically associated with expectation of death in the 187 patients included. In the last 48 h, routine (70.6%) and biomarkers (41.7%) blood tests were performed, at higher extent on patients whose death was not expected. Many symptoms classified as severe were reported when death was highly expected, except for agitation and respiratory fatigue which were reported when death was moderately expected. A high Norton score and absence of anti-bedsore mattress were associated with unexpected death and poor quality of dying, as summarized by MCA. Quality of dying was perceived as good by nurses when death was moderately and highly expected. Physicians rated more frequently than nurses the quality of dying as good or very good, respectively 78.6 and 57.8%, denoting a fair agreement between the two professionals (k = 0.24, P < 0.001). The palliative care consultant was requested for only two patients. Conclusion Staff in medical and surgical wards still deal inadequately with the needs of dying people. Presence of hospital-based specialist palliative care could lead to improvements in the patients’ quality of life.
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Affiliation(s)
- Filippo Binda
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy.
| | - Marco Clari
- Department of Public Health and Paediatrics - University of Torino, Via Santena, 5, 10126, Torino, Italy
| | - Gabriella Nicolò
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Simone Gambazza
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Barbara Sappa
- Department of Healthcare Professions (General Internal Medicine Unit), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Paola Bosco
- Department of Healthcare Professions (High-dependency Unit), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
| | - Dario Laquintana
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122, Milan, Italy
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Crawford GB, Dzierżanowski T, Hauser K, Larkin P, Luque-Blanco AI, Murphy I, Puchalski CM, Ripamonti CI. Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines. ESMO Open 2021; 6:100225. [PMID: 34474810 PMCID: PMC8411064 DOI: 10.1016/j.esmoop.2021.100225] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/08/2023] Open
Abstract
•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.
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Affiliation(s)
- G B Crawford
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - T Dzierżanowski
- Department of Social Medicine and Public Health, Medical University of Warsaw, Warsaw, Poland
| | - K Hauser
- Palliative and Supportive Care Department Cabrini Health, Prahran, Victoria, Australia
| | - P Larkin
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - A I Luque-Blanco
- Palliative Care Unit, Hospital Sant Joan de Déu, Palma de Mallorca, Spain
| | - I Murphy
- Marymount University Hospital and Hospice, Curraheen, Cork, Ireland
| | - C M Puchalski
- Department of Medicine and Health Sciences, The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - C I Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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Yamout R, Viallard ML, Hoteit S, Abou-Zeid H, Shebbo F, Naccache N. Does the addition of dexmedetomidine to morphine have any clinical benefit on the treatment of pain in patients with metastatic cancer? A pilot study. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1919045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Rana Yamout
- Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marcel-Louis Viallard
- Department of Anesthesiology, University Hospital Necker Enfants-Malades, Paris, France
| | - Samer Hoteit
- Department of Anesthesiology, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Hicham Abou-Zeid
- Department of Anesthesiology, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Fadia Shebbo
- Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nicole Naccache
- Department of Anesthesiology, Hotel Dieu de France Hospital, Beirut, Lebanon
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Bosco N, Cappellato V. Preparing for a good death? Palliative care representations in the italian public television programming. DEATH STUDIES 2021; 46:1963-1972. [PMID: 33476248 DOI: 10.1080/07481187.2021.1876788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The difficulty in accepting death is a constant that transcends differences of time and place. The literature shows that the dying is often subjected to invasive procedures with significant consequences on individual wellbeing and public health. If death is hard to accept even for the practitioners, what happens in the broader population? What narratives surround the end of life? The study focuses on the Italian context and its transformations, the public's understanding of palliative care, and the television programs dealing with hospice and palliative care aired by the Italian public broadcasting company from the 1950s to the present day.
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Affiliation(s)
- Nicoletta Bosco
- Department of Cultures, Politics and Society, University of Turin, Torino, Italy
| | - Valeria Cappellato
- Department of Cultures, Politics and Society, University of Turin, Torino, Italy
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Smith N, Rajabali S, Hunter KF, Chambers T, Fasinger R, Wagg A. Bladder and bowel preferences of patients at the end of life: a scoping review. Int J Palliat Nurs 2020; 26:432-442. [PMID: 33331214 DOI: 10.12968/ijpn.2020.26.8.432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Following patient preferences at the end of life should improve outcomes of care, yet patient preferences regarding bladder and bowel care are not often accommodated, as they are not well known in the literature. AIMS This scoping review sought to identify bladder and bowel care preferences of patients at the end of life in published literature. METHODS Papers published in or after 1997 (in English) that focused on adult preferences for bladder and bowel care at the end of life were included. FINDINGS Scant literature exists on preferences for bladder and bowel care for adult patients at end of life. Further investigation is warranted to arrive at a better understanding of preferences regarding bladder and bowel symptom management. CONCLUSIONS Future research should explore if prioritising the symptoms caused by incontinence, among the many symptoms experienced at the end of life, could be achieved through careful questioning and development of a standardised tool focused on improving patient care and incorporating patient preferences for care.
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Affiliation(s)
| | - Saima Rajabali
- Clinical Trials Project Coordinator for Division of Geriatric Medicine, Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta
| | - Kathleen F Hunter
- Professor, Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta
| | - Thane Chambers
- Research Impact Librarian, Faculty of Nursing, University of Alberta
| | - Robin Fasinger
- Professor, Faculty of Medicine and Dentistry, University of Alberta
| | - Adrian Wagg
- Professor/Director, Faculty of Medicine and Dentistry, University of Alberta
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7
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Angheluta AA, Gonella S, Sgubin C, Dimonte V, Bin A, Palese A. When and how clinical nurses adjust nursing care at the end-of-life among patients with cancer: Findings from multiple focus groups. Eur J Oncol Nurs 2020; 49:101856. [PMID: 33120222 DOI: 10.1016/j.ejon.2020.101856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Defining patients as 'terminally-ill' may be difficult. Therefore, determining when to shift the goal of care from curative to comfort care may be extremely challenging. The aim of this study was to merge when and how Registered Nurses (RNs) and Nurses' Assistants (NAs) adjust end-of-life care to pursue patient comfort at the end of their lives. METHODS A descriptive qualitative study based on multiple focus groups was performed in 2017 according to the COnsolidated criteria for REporting Qualitative research guidelines. In all, 25 RNs and 16 NAs across seven north-east Italian facilities that provide end-of-life care, voluntarily participated in the study. Each focus group was conducted following the same interview guide with open-ended questions, and was audiotaped. A thematic analysis was applied to interview transcripts. RESULTS The process of nursing care plan adjustment is based upon two main themes, around 'when' and 'how' to adjust it. Regarding when, 'Detecting the turning point', and 'Being ready to change continuously until the end' emerged as the main sub-themes. Regarding how, 'Weighing harms and benefits of nursing care interventions'; 'Advocating for patients' wishes', 'Sharing the adjustments inside the team at different levels', 'Involving family in the adjustments of nursing care'; and 'Allowing care to move away from evidence-based practice' were the sub-themes emerged. CONCLUSIONS Shedding light on the implicit decisional processes that inform care adjustments and the implementation of related strategies is essential to improve the quality of end-of-life care given that an early detection of the terminal phase has been reported to result in changes of care improving outcomes.
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Affiliation(s)
| | | | | | | | - Alessandra Bin
- Azienda Sanitaria Universitaria Integrata di Udine, Oncological Department, Udine, Italy
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Bertocchi E, Artioli G, Rabitti E, Bedini G, Di Leo S, Asensio Sierra NM, Braglia L, Costantini M. Quality of cancer end-of-life care: discordance between bereaved relatives and professional proxies. BMJ Support Palliat Care 2020; 12:bmjspcare-2019-002108. [PMID: 32690478 DOI: 10.1136/bmjspcare-2019-002108] [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: 11/09/2019] [Revised: 04/07/2020] [Accepted: 06/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Quality of care for patients dying in hospital remains suboptimal. A major problem is the identification of valid sources of information about the views and experiences of dying patients and their relatives. AIM This study aimed to estimate the agreement on quality of end-of-life care from the perspectives of bereaved relatives, physicians and nurses interviewed after the patients' death. DESIGN In this prospective study, we interviewed, after the patient death, the bereaved relatives, the attending physicians and the reference nurses, using the Toolkit After-death Family Interview and the View Of Informal Carers-Evaluation of Services (VOICES). Agreement was assessed using Lin's concordance correlation coefficient, Cohen's kappa, overall concordance correlation coefficient and Fleiss' kappa. SETTING/PARTICIPANTS We enrolled a consecutive series of 40 adult patients who died of cancer between January and December 2016 who had spent at least 48 hours in the medical oncology ward of the Santa Maria Hospital of Reggio Emilia, Italy. RESULTS We interviewed all physicians and nurses, and 26 (65.0%) out of 40 relatives. We found a poor agreement on overall quality of care among the three proxies (+0.21; -0.04 to 0.44), between relatives and nurses (+0.05; -0.39 to +0.47), and between relatives and physicians (+0.25; -0.13 to +0.57). A similar poor agreement was observed for all the other Toolkit and VOICES scales. CONCLUSIONS The agreement was rather poor, confirming previous results in different settings. Information from professional proxies should not be used for assessing the quality of care or for estimating missing information from bereaved relatives.
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Affiliation(s)
- Elisabetta Bertocchi
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Giovanna Artioli
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Elisa Rabitti
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Gabriele Bedini
- Casa Madonna dell'Uliveto Hospice, Albinea, Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Silvia Di Leo
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Nuria Maria Asensio Sierra
- Medicina Oncologica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Luca Braglia
- Research and Statistics Infrastructure, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
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Ross L, Taverner J, John J, Baisch A, Irving L, Philip J, Smallwood N. Burden of diagnostic investigations at the end of life for people with chronic obstructive pulmonary disease. Intern Med J 2020; 51:1835-1839. [PMID: 32548876 DOI: 10.1111/imj.14943] [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: 09/11/2019] [Revised: 02/23/2020] [Accepted: 03/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is an incurable, chronic condition that leads to significant morbidity and mortality, with most patients dying in hospital. While diagnostic tests are important for actively managing patients during hospital admissions, the balance between benefit and harm should always be considered. This is particularly important when patients reach the end of life, when the focus is to reduce burdensome interventions. AIMS To examine the use of diagnostic testing in a cohort of people with COPD who died in hospital. METHODS Retrospective medical record audits were completed at two Australian hospitals (Royal Melbourne Hospital and Northeast Health Wangaratta), with all patients who died from COPD over 12 years between 1 January 2004 and 31 December 2015 included. RESULTS Three hundred and forty-three patients were included, with a median of 11 diagnostic testing episodes per patient. Undergoing higher numbers of diagnostic tests was associated with younger age, intensive care unit admission and non-invasive ventilation use. Reduced testing was associated with recent hospital admission for COPD, domiciliary oxygen use and a prior admission with documentation limiting medical treatment. Most patients underwent diagnostic tests in the last 2 days of life, and 12% of patients had ongoing diagnostic tests performed after a documented decision was made to change the goal of care to provide comfort care only. CONCLUSION There were missed opportunities to reduce the burden of diagnostic tests and focus on comfort at the end of life. Increased physician education regarding communication and end-of-life care, including recognising active dying may address these issues.
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Affiliation(s)
- Lauren Ross
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - John Taverner
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jennifer John
- Department of Rural Health, University of Melbourne, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
| | - Andreas Baisch
- Department of Medicine, Northeast Health Wangaratta, Wangaratta, Victoria, Australia.,Department of Rural Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Palliative Medicine, University of Melbourne, St Vincent's Hospital and Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Natasha Smallwood
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Melbourne, Victoria, Australia
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Martens MJ, Janssen DJ, Schols JM, van den Beuken-van Everdingen MH. Opioid Prescribing Behavior in Long-Term Geriatric Care in the Netherlands. J Am Med Dir Assoc 2018; 19:974-980. [DOI: 10.1016/j.jamda.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
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11
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Oliveira I, Fothergill-Bourbonnais F, McPherson C, Vanderspank-Wright B. Battling a Tangled Web: The Lived Experience of Nurses Providing End-of-Life Care on an Acute Medical Unit. Res Theory Nurs Pract 2018; 30:353-378. [PMID: 28304263 DOI: 10.1891/1541-6577.30.4.353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Meeting the heath care needs of patients at the end of life is becoming more complex. In Canada, most patients with life-limiting illness will die in hospitals, many on medical units. Yet, few studies have qualitatively investigated end-of-life care (EOLC) in this context, or from the perspectives of nurses providing EOLC. The purpose of this study was to seek to understand the lived experience of nurses on a medical unit providing EOLC to patients. Interpretive phenomenology guided the method and analysis. Individual face-to-face interviews were conducted with 10 nurses from 2 hospital medical units. The underlying essence of these nurses' experiences was that of "battling a tangled web." Battling a tangled web represented their struggles in attempting to provide EOLC in an environment that was not always conducive to it. Seven themes were generated from the analysis: caring in complexity, caught in a tangled web, bearing witness to suffering, weaving a way to get there: struggling through the process, creating comfort for the patient, working through the dying process with the family, and finding a way through the web. The findings contribute to an understanding of the experiences of nurses in providing EOLC on a medical unit including perceived facilitators and barriers.
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12
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Omar Daw Hussin E, Wong LP, Chong MC, Subramanian P. Nurses’ perceptions of barriers and facilitators and their associations with the quality of end‐of‐life care. J Clin Nurs 2017; 27:e688-e702. [DOI: 10.1111/jocn.14130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Emni Omar Daw Hussin
- Department of Nursing Science Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Li Ping Wong
- Department of Social and Preventive Medicine Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Mei Chan Chong
- Department of Nursing Science Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Pathmawathi Subramanian
- Pathmawathi Subramanian Nursing Synergy Ptd Ltd. 18.USJ 1/3K, USJ 1 Subang Jaya 47100 Malaysia
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13
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Pereira MED, Barbosa A, Dixe MDA. Palliative care for end-of-life patients in a basic emergency service. Scand J Caring Sci 2017; 32:1056-1063. [PMID: 29205442 DOI: 10.1111/scs.12551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/13/2017] [Indexed: 11/29/2022]
Abstract
This research sought to describe the care provided by the nursing staff of the Western Department of the Basic Emergency Service for end-of-life patients. This was a retrospective, quantitative, exploratory and descriptive (level I) study, which sought to research the nursing records of 83 patients from admission to death. Patients who met the following inclusion criteria were considered eligible: adults; had an oncological or nononcological, advanced and irreversible chronic disease; and died in the Basic Emergency Service in the period from January 2011 to December 2012. An instrument was created for data collection, the content, relevance and adequacy of which was validated by a panel of experts in the area of palliative care. The study protocol was approved by the Institutional Ethics Committee. The main results indicate that the majority of patients died in the Observation Room in a period between the first two and twenty-four hours. Nursing interventions favoured technical-instrumental care related to medical prescriptions and service routines such as venous punctures, catheterisations, taking blood samples for analysis, aspiration of secretions, intravenous administration of fluids and drugs for symptomatic control, and monitoring of vital parameters and the state of consciousness. With the proximity of death, the nurses favoured the registration of cardiorespiratory arrest, cardiopulmonary resuscitation manoeuvres and aspiration of secretions. In the recognition of predictive factors of imminent death, the nurses favoured the patient's entry into a comatose state and aggravation of asthenia. In most patients, the entry into agony phase was not diagnosed.
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Affiliation(s)
| | - António Barbosa
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Maria Dos Anjos Dixe
- Escola Superior de Saúde do Instituto Politécnico de Leiria, Unidade de investigação em Saúde, Leiria, Portugal
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14
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Montgomery GH, Sucala M, Baum T, Schnur JB. Hypnosis for Symptom Control in Cancer Patients at the End-of-Life: A Systematic Review. Int J Clin Exp Hypn 2017; 65:296-307. [PMID: 28506144 PMCID: PMC5734627 DOI: 10.1080/00207144.2017.1314728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hypnosis has been shown to alleviate symptoms and side effects of cancer and its treatment. However, less is known about the use of hypnosis at the end of life in individuals with cancer. Our goal was to systematically review the literature on the use of hypnosis to manage the most common symptoms of end-of-life cancer patients: fatigue, sleep disturbances, pain, appetite loss, and dyspnea. EMBASE, MEDLINE, COCHRANE, PsychINFO, and SCOPUS databases were searched from inception through November 7, 2016. No studies met the inclusion criteria. It appears that hypnosis has never been rigorously tested as a means to ameliorate the most common symptoms in individuals with cancer at the end of their lives. This finding is troubling, as it strongly implies that a population most in need has been largely neglected. However, a clear future research direction is revealed that may have significant clinical impact.
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Affiliation(s)
- Guy H Montgomery
- a Icahn School of Medicine at Mount Sinai , New York , New York , USA
| | - Madalina Sucala
- a Icahn School of Medicine at Mount Sinai , New York , New York , USA
| | - Tessa Baum
- a Icahn School of Medicine at Mount Sinai , New York , New York , USA
| | - Julie B Schnur
- a Icahn School of Medicine at Mount Sinai , New York , New York , USA
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In-hospital elderly mortality and associated factors in 12 Italian acute medical units: findings from an exploratory longitudinal study. Aging Clin Exp Res 2017; 29:517-527. [PMID: 27155980 DOI: 10.1007/s40520-016-0576-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Given the progressive demographic ageing of the population and the National Health System reforms affecting care at the bedside, a periodic re-evaluation of in-hospital mortality rates and associated factors is recommended. AIMS To describe the occurrence of in-hospital mortality among patients admitted to acute medical units and associated factors. Two hypotheses (H) were set as the basis of the study: patients have an increased likelihood to die H1: at the weekend when less nursing care is offered; H2: when they receive nursing care with a skill-mix in favour of Nursing Aides instead of Registered Nurses. METHODS Secondary analysis of a prospective study of patients >65 years consecutively admitted in 12 Italian medical units. Data on individual and nursing care variables were collected and its association with in-hospital mortality was analysed by stepwise logistic regression analysis. RESULTS In-hospital mortality occurrence was 6.8 %, and 37 % of the patients died during the weekend. The logistic regression model explained 34.3 % (R 2) of the variance of in-hospital mortality: patients were six times (95 % CI = 3.632-10.794) more likely at risk of dying at weekends; those with one or more AEDs admissions in the last 3 months were also at increased risk of dying (RR 1.360, 95 % CI = 1.024-1.806) as well as those receiving more care from family carers (RR = 1.017, 95 % CI = 1.009-1.025). At the nursing care level, those patient receiving less care by RNs at weekends were at increased risk of dying (RR = 2.236, 95 % CI = 1.270-3.937) while those receiving a higher skill-mix, thus indicating that more nursing care was offered by RNs instead of NAs were at less risk of dying (RR = 0.940, 95 % CI = 0.912-0.969). CONCLUSIONS Within the limitations of this secondary analysis, in addition to the role of some clinical factors, findings suggest redesigning acute care at weekends ensuring consistent care both at the hospital and at the nursing care levels.
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16
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Ameneiros-Lago E, Carballada-Rico C, Garrido-Sanjuán JA. Mortalidad esperable en Medicina Interna: ¿cómo son los últimos días de vida en los pacientes en los que la muerte es previsible? ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.medipa.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Shaku F, Tsutsumi M. The Effect of Providing Life Support on Nurses’ Decision Making Regarding Life Support for Themselves and Family Members in Japan. Am J Hosp Palliat Care 2016; 33:917-923. [DOI: 10.1177/1049909115624655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Decision making in terminal illness has recently received increased attention. In Japan, patients and their families typically make decisions without understanding either the severity of illness or the efficacy of life-supporting treatments at the end of life. Japanese culture traditionally directs the family to make decisions for the patient. This descriptive study examined the influence of the experiences of 391 Japanese nurses caring for dying patients and family members and how that experience changed their decision making for themselves and their family members. The results were mixed but generally supported the idea that the more experience nurses have in caring for the dying, the less likely they would choose to institute lifesupport measures for themselves and family members. The results have implications for discussions on end-of-life care.
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Affiliation(s)
- Fumio Shaku
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Madoka Tsutsumi
- Primary Care and Medical Education, University of Tsukuba, Ibaraki, Japan
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18
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Campos-Calderón C, Montoya-Juárez R, Hueso-Montoro C, Hernández-López E, Ojeda-Virto F, García-Caro MP. Interventions and decision-making at the end of life: the effect of establishing the terminal illness situation. BMC Palliat Care 2016; 15:91. [PMID: 27821105 PMCID: PMC5100335 DOI: 10.1186/s12904-016-0162-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 10/26/2016] [Indexed: 11/10/2022] Open
Abstract
Background Many ‘routine’ interventions performed in hospital rooms have repercussions for the comfort of the patient, and the decision to perform them should depend on whether the patient is identified as in a terminal phase. The aim of this study is to analyse the health interventions performed and decisions made in the last days of life in patients with advanced oncological and non-oncological illness to ascertain whether identifying the patient’s terminal illness situation has any effect on these decisions. Methods Retrospective study of the clinical histories of deceased patients in four hospitals in Granada (Spain) in 2010. Clinical histories corresponding to the last three months of the patient’s life were reviewed. Results A total of 202 clinical histories were reviewed, 60 % of which were those of non-oncology patients. Opioid prescriptions (58.4 %), palliative sedation (35.1 %) and Do Not Resuscitate (DNR) orders (34.7 %) were the decisions most often reflected in the histories, and differences in these decisions were found between patients registered as terminal and those who were not registered as terminal. The most frequent interventions in the final 14 days and 48 h were parenteral hydration (96–83 %), peripheral venous catheter (90.1–82 %) and oxygen therapy (81.2–70.5 %). There were statistically significant differences between the patients who were registered as terminal and those not registered as terminal in the number of interventions applied in the final 14 days and 48 h (p = 0.01–p = 0.00) and in many of the described treatments. Conclusion The recognition of a patient’s terminal status in the clinical history conditions the decisions that are made and is generally associated with a lower number of interventions.
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Affiliation(s)
- C Campos-Calderón
- Foundation of Progress and Health, Andalusian Health Service, Granada, Spain
| | | | | | - E Hernández-López
- General Hospital of the Virgen de las Nieves of Granada, Andalusian Health Service, Granada, Spain
| | - F Ojeda-Virto
- Hospital Santa Ana, Andalusian Health Service, Motril, Spain
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Sato K, Miyashita M, Morita T, Tsuneto S, Shima Y. End-of-Life Medical Treatments in the Last Two Weeks of Life in Palliative Care Units in Japan, 2005–2006: A Nationwide Retrospective Cohort Survey. J Palliat Med 2016; 19:1188-1196. [DOI: 10.1089/jpm.2016.0108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kazuki Sato
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan
- Department of Adult Nursing/Palliative Care Nursing, School of Health, Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan
- Department of Adult Nursing/Palliative Care Nursing, School of Health, Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
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The last days of life: symptom burden and impact on nutrition and hydration in cancer patients. Curr Opin Support Palliat Care 2016; 9:346-54. [PMID: 26509860 DOI: 10.1097/spc.0000000000000171] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW To examine the symptom burden in cancer patients during the last days of life, its impact on nutrition and hydration, and the role of artificial nutrition and hydration in the final days. RECENT FINDINGS During the last days of life, cancer patients often experience progressive functional decline and worsening symptom burden. Many symptoms such as anorexia-cachexia, dysphagia, and delirium could impair oral intake. These, coupled with refractory cachexia, contribute to persistent weight loss and decreased quality of life. Furthermore, the inability to eat/drink and body image changes can result in emotional distress for patients and caregivers. Clinicians caring for these individuals need to ensure longitudinal communication about goals of care, education about the natural process of dying, optimization of symptom management, and provide appropriate emotional support for patients and caregivers. There is a lack of evidence to support that artificial nutrition and hydration can improve outcomes during the last days of life. Artificial nutrition is not recommended because of its invasive nature, whereas artificial hydration may be considered on a case-by-case basis. SUMMARY This review highlights the need to conduct further research on symptom burden, nutrition, and hydration during the last days of life.
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21
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Unexpected death in palliative care: what to expect when you are not expecting. Curr Opin Support Palliat Care 2016; 9:369-74. [PMID: 26509862 DOI: 10.1097/spc.0000000000000174] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Death is a certainty in life. Yet, the timing of death is often uncertain. When death occurs suddenly and earlier than anticipated, it is considered as an unexpected death. In this article, we shall discuss when is death expected and unexpected, and review the frequency, impact, causes, and approach to unexpected death in the palliative care setting. RECENT FINDINGS Even in the palliative care setting in which death is relatively common, up to 5% of deaths in hospice and 10% of deaths in palliative care units were considered to be unexpected. Unexpected death has significant impact on care, including unrealized dreams and unfinished business among patients, a sense of uneasiness and complicated bereavement among caregivers, and uncertainty in decision making among healthcare providers. Clinicians may minimize the impact of unexpected events by improving their accuracy of prognostication, communicating the uncertainty with patients and families, and helping them to expect the unexpected by actively planning ahead. Furthermore, because of the emotional impact of unexpected death on bereaved caregivers, clinicians should provide close monitoring and offer prompt treatment for complicated grief. SUMMARY Further research is needed to understand how we can better predict and address unexpected events.
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Abstract
PURPOSE OF REVIEW Studies in different countries and settings of care have reported the quality of care for the dying patients as suboptimal. Care pathways have been developed with the aim of ensuring that dying patients and their family members received by health professionals the most appropriate care. This review presents and discusses the evidence supporting the effectiveness of the end-of-life care pathways. RECENT FINDINGS Two Cochrane systematic reviews updated at June 2013 did not identify studies that met minimal criteria for inclusion. One randomized cluster trial aimed at assessing the effectiveness of the Liverpool Care Pathway in hospitalized cancer patients was subsequently published. The trial did not find a significant difference in the overall quality of care, the primary end-point, but two out of nine secondary outcomes - respect, dignity, and kindness, and control of breathlessness showed significant improvements. Afterwards, we did not find any other potentially eligible published study. SUMMARY The overall amount of evidence supporting the dissemination of end-of-life care pathways is rather poor. One negative randomized trial suggests the pathways have the potential to reduce the gap between hospital and hospices. Further research is needed to understand the potential benefit of end-of-life care pathways.
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Bruera S, Chisholm G, Dos Santos R, Bruera E, Hui D. Frequency and factors associated with unexpected death in an acute palliative care unit: expect the unexpected. J Pain Symptom Manage 2015; 49:822-7. [PMID: 25499421 PMCID: PMC4441861 DOI: 10.1016/j.jpainsymman.2014.10.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 10/03/2014] [Accepted: 10/22/2014] [Indexed: 11/21/2022]
Abstract
CONTEXT Few studies have examined the frequency of unexpected death and its associated factors in a palliative care setting. OBJECTIVES To determine the frequency of unexpected death in two acute palliative care units (APCUs); to compare the frequency of signs of impending death between expected and unexpected deaths; and to determine the predictors associated with unexpected death. METHODS In this prospective, longitudinal, observational study, consecutive patients admitted to two APCUs were enrolled and physical signs of impending death were documented twice daily until discharge or death. Physicians were asked to complete a survey within 24 hours of APCU death. The death was considered unexpected if the physician answered "yes" to the question "Were you surprised by the timing of the death?" RESULTS In total, 193 of 203 after-death assessments (95%) were collected for analysis. Nineteen of 193 patients died unexpectedly (10%). Signs of impending death, including non-reactive pupils, inability to close eyelids, decreased response to verbal stimuli, drooping of nasolabial folds, peripheral cyanosis, pulselessness of the radial artery, and respiration with mandibular movement, were documented more frequently in expected deaths than unexpected deaths (P < 0.05). Longer disease duration was associated with unexpected death (33 months vs. 12 months, P = 0.009). CONCLUSION Unexpected death occurred in an unexpectedly high proportion of patients in the APCU setting and was associated with fewer signs of impending death. Our findings highlight the need for palliative care teams to be prepared for the unexpected.
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Affiliation(s)
- Sebastian Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Gary Chisholm
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | | | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care. J Am Med Dir Assoc 2015; 16:535.e13-20. [PMID: 25843621 DOI: 10.1016/j.jamda.2015.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services. DESIGN Prospective cohort study with a follow-up of 6 months. SETTING Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy. PARTICIPANTS Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks. MEASUREMENTS At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days). RESULTS For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. CONCLUSIONS Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.
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Bergenholtz H, Jarlbaek L, Hølge-Hazelton B. The culture of general palliative nursing care in medical departments: an ethnographic study. Int J Palliat Nurs 2015; 21:193-201. [DOI: 10.12968/ijpn.2015.21.4.193] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Heidi Bergenholtz
- PhD student, The Regional Research Unit, Region Zealand, Roskilde/Koege Hospitals, Denmark
| | - Lene Jarlbaek
- Consultant in Oncology, The Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Denmark
| | - Bibi Hølge-Hazelton
- Associate Research Professor at Roskilde/Koege Hospitals and The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Denmark
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Steindal SA, Bredal IS, Ranhoff AH, Sørbye LW, Lerdal A. The last three days of life: a comparison of pain management in the young old and the oldest old hospitalised patients using the Resident Assessment Instrument for Palliative Care. Int J Older People Nurs 2014; 10:263-72. [PMID: 25418556 DOI: 10.1111/opn.12076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pain is a common symptom in older patients at the end of life. Little research has evaluated pain management among the oldest hospitalised dying patients. AIMS AND OBJECTIVES To compare the pain characteristics documented by healthcare workers for the young old and the oldest old hospitalised patients and the types of analgesics administered in the last three days of life. DESIGN A retrospective cross-sectional comparative study. METHODS The study included 190 patients from a Norwegian general hospital: 101 young old patients (aged 65-84 years) and 89 oldest old patients (aged 85-100 years). Data were extracted from electronic patient records (EPRs) using the Resident Assessment Instrument for Palliative Care. RESULTS No significant differences were found between the young old and the oldest old patients with regard to pain characteristics. Pain intensity was poorly recorded in the EPRs. Most of the patients received adequate pain control. Morphine was the most frequently administered analgesic for dying patients. Compared to the oldest old patients, a greater proportion of the young old patients received paracetamol combined with codeine (OR = 3.25, 95% CI 1.02-10.40). CONCLUSIONS There appeared to be no differences in healthcare workers' documentation of pain characteristics in young old and oldest old patients, but young old patients were more likely to receive paracetamol in combination with codeine. IMPLICATIONS FOR PRACTICE A limitation of the study is the retrospective design and that data were collected from a single hospital. Therefore, caution should be taken for interpretation of the results. The use of systematic patient-reported assessments in combination with feasible validated tools could contribute to more comprehensive documentation of pain intensity and improved pain control.
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Affiliation(s)
- Simen Alexander Steindal
- Institute of Nursing and Health, Diakonhjemmet University College, Oslo, Norway.,Palliative Care Unit, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Inger Schou Bredal
- Surgery and Transplantation Department, Faculty of Medicine, University of Oslo and Cancer, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Anette Hylen Ranhoff
- Medical Department, Diakonhjemmet Hospital, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Anners Lerdal
- Department of Research, Lovisenberg Diakonale Hospital, Oslo, Norway.,Deptartment of Nursing Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
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Rejnö Å, Berg L. Strategies for handling ethical problems in end of life care: obstacles and possibilities. Nurs Ethics 2014; 22:778-89. [PMID: 25288511 DOI: 10.1177/0969733014547972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In end of life care, ethical problems often come to the fore. Little research is performed on ways or strategies for handling those problems and even less on obstacles to and possibilities of using such strategies. A previous study illuminated stroke team members’ experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. These findings have been further explored in this study. Objective: The aim of the study was to illuminate obstacles and possibilities perceived by stroke team members in using strategies for handling ethical problems when caring for patients afflicted by sudden and unexpected death caused by stroke. Research design: A qualitative method with combined deductive and inductive content analysis was utilized. Participants and research context: Data were collected through individual interviews with 15 stroke team members working in stroke units of two associated county hospitals in western Sweden. Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. Permission was also obtained from the director of each stroke unit. Findings: All the studied strategies for handling of ethical problems were found to have both obstacles and possibilities. Uncertainty is shown as a major obstacle and unanimity as a possibility in the use of the strategies. The findings also illuminate the value of the concept “the patient’s best interests” as a starting point for the carers’ ethical reasoning. Conclusion: The concept “the patient’s best interests” used as a starting point for ethical reasoning among the carers is not explicitly defined yet, which might make this value difficult to use both as a universal concept and as an argument for decisions. Carers therefore need to strengthen their argumentation and reflect on and use ethically grounded arguments and defined ethical values like dignity in their clinical work and decisions.
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Affiliation(s)
- Åsa Rejnö
- Skaraborg Hospital Skövde, Sweden; University West, Sweden
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Jors K, Adami S, Xander C, Meffert C, Gaertner J, Bardenheuer H, Buchheidt D, Mayer-Steinacker R, Viehrig M, George W, Becker G. Dying in cancer centers: do the circumstances allow for a dignified death? Cancer 2014; 120:3254-60. [PMID: 25200536 DOI: 10.1002/cncr.28702] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior research has shown that hospitals are often ill-prepared to provide care for dying patients. This study assessed whether the circumstances for dying on cancer center wards allow for a dignified death. METHODS In this cross-sectional study, the authors surveyed physicians and nurses in 16 hospitals belonging to 10 cancer centers in Baden-Wuerttemberg, Germany. A revised questionnaire from a previous study was used, addressing the following topics regarding end-of-life care: structural conditions (ie, rooms, staff), education/training, working environment, family/caregivers, medical treatment, communication with patients, and dignified death. RESULTS In total, 1131 surveys (response rate = 50%) were returned. Half of the participants indicated that they rarely have enough time to care for dying patients, and 55% found the rooms available for dying patients unsatisfactory. Only 19% of respondents felt that they had been well-prepared to care for the dying (physicians = 6%). Palliative care staff reported much better conditions for the dying than staff from other wards (95% of palliative care staff indicated that patients die in dignity on their ward). Generally, physicians perceived the circumstances much more positively than nurses, especially regarding communication and life-prolonging measures. Overall, 57% of respondents believed that patients could die with dignity on their ward. CONCLUSIONS Only about half of the respondents perceived that a dignified death is possible on their ward. We recommend that cancer centers invest more in staffing, adequate rooms for dying patients, training in end-of-life care, advance-care planning standards, and the early integration of specialist palliative care services.
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Affiliation(s)
- Karin Jors
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany
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Kennedy C, Brooks-Young P, Brunton Gray C, Larkin P, Connolly M, Wilde-Larsson B, Larsson M, Smith T, Chater S. Diagnosing dying: an integrative literature review. BMJ Support Palliat Care 2014; 4:263-70. [PMID: 24780536 PMCID: PMC4145438 DOI: 10.1136/bmjspcare-2013-000621] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/18/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND To ensure patients and families receive appropriate end-of-life care pathways and guidelines aim to inform clinical decision making. Ensuring appropriate outcomes through the use of these decision aids is dependent on timely use. Diagnosing dying is a complex clinical decision, and most of the available practice checklists relate to cancer. There is a need to review evidence to establish diagnostic indicators that death is imminent on the basis of need rather than a cancer diagnosis. AIM To examine the evidence as to how patients are judged by clinicians as being in the final hours or days of life. DESIGN Integrative literature review. DATA SOURCES Five electronic databases (2001-2011): Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL. The search yielded a total of 576 hits, 331 titles and abstracts were screened, 42 papers were retrieved and reviewed and 23 articles were included. RESULTS Analysis reveals an overarching theme of uncertainty in diagnosing dying and two subthemes: (1) 'characteristics of dying' involve dying trajectories that incorporate physical, social, spiritual and psychological decline towards death; (2) 'treatment orientation' where decision making related to diagnosing dying may remain focused towards biomedical interventions rather than systematic planning for end-of-life care. CONCLUSIONS The findings of this review support the explicit recognition of 'uncertainty in diagnosing dying' and the need to work with and within this concept. Clinical decision making needs to allow for recovery where that potential exists, but equally there is the need to avoid futile interventions.
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Affiliation(s)
- Catriona Kennedy
- Department of Nursing and Midwifery, University of Limerick, Edinburgh Napier University, Limerick, Ireland
| | | | | | | | - Michael Connolly
- All Ireland Institute for Hospice and Palliative Care/University College Dublin, Dublin, Ireland
| | | | - Maria Larsson
- University of Karlstad Universitetsgatan 2, Karlstad, Sweden
| | - Tracy Smith
- University of Karlstad Universitetsgatan 2, Karlstad, Sweden
| | - Susie Chater
- Department of Palliative Medicine, St Columba's Hospice, Edinburgh, UK
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30
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Clark D, Armstrong M, Allan A, Graham F, Carnon A, Isles C. Imminence of death among hospital inpatients: Prevalent cohort study. Palliat Med 2014; 28:474-479. [PMID: 24637342 PMCID: PMC4845030 DOI: 10.1177/0269216314526443] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a dearth of evidence on the proportion of the hospital population at any one time, that is in the last year of life, and therefore on how hospital policies and services can be oriented to their needs. AIM To establish the likelihood of death within 12 months of a cohort of hospital inpatients on a given census date. DESIGN Prevalent cohort study. PARTICIPANTS In total, 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010. RESULTS In all, 3098 (28.8%) patients died during follow-up: 2.9% by 7 days, 8.9% by 30 days, 16.0% by 3 months, 21.2% by 6 months, 25.5% by 9 months and 28.8% by 12 months. Deaths during the index admission accounted for 32.3% of all deaths during the follow-up year. Mortality rose steeply with age and was three times higher at 1 year for patients aged 85 years and over compared to those who were under 60 years (45.6% vs 13.1%; p < 0.001). In multivariate analyses, men were more likely to die than women (odds ratio: 1.18, 95% confidence interval: 0.95-1.47) as were older patients (odds ratio: 4.99, 95% confidence interval: 3.94-6.33 for those who were 85 years and over compared to those who were under 60 years), deprived patients (odds ratio: 1.17, 95% confidence interval: 1.01-1.35 for most deprived compared to least deprived quintile) and those admitted to a medical specialty (odds ratio: 3.13, 95% confidence interval: 2.48-4.00 compared to surgical patients). CONCLUSION Large numbers of hospital inpatients have entered the last year of their lives. Such data could assist in advocacy for these patients and should influence end-of-life care strategies in hospital.
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Affiliation(s)
- David Clark
- 1 School of Interdisciplinary Studies, University of Glasgow, Dumfries, UK
| | - Matthew Armstrong
- 2 Healthcare Information Group, Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Ananda Allan
- 3 Department of Public Health, NHS Dumfries & Galloway, Dumfries, UK
| | | | - Andrew Carnon
- 3 Department of Public Health, NHS Dumfries & Galloway, Dumfries, UK
| | - Christopher Isles
- 5 Dumfries and Galloway Royal Infirmary, NHS Dumfries & Galloway, Dumfries, UK
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Cipolletta S, Oprandi N. What is a good death? Health care professionals' narrations on end-of-life care. DEATH STUDIES 2014; 38:20-27. [PMID: 24521042 DOI: 10.1080/07481187.2012.707166] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The present study explores how health professionals evaluate care at the end of life and what they consider to be a good death. We conducted four focus groups with 37 health professionals and used a grounded theory-based approach to analyze the transcripts of the discussions. A lack of organization, training, formalized procedures, and communication with dying persons and their families emerged. Difficulty in defining a good death derived from the ethical dilemmas that involved places to die, palliative care, and end-of-life decision making.
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Affiliation(s)
- Sabrina Cipolletta
- a Department of General Psychology , University of Padova , Padova , Italy
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Costantini M, Pellegrini F, Di Leo S, Beccaro M, Rossi C, Flego G, Romoli V, Giannotti M, Morone P, Ivaldi GP, Cavallo L, Fusco F, Higginson IJ. The Liverpool Care Pathway for cancer patients dying in hospital medical wards: a before-after cluster phase II trial of outcomes reported by family members. Palliat Med 2014; 28:10-7. [PMID: 23652840 DOI: 10.1177/0269216313487569] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain. AIM Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital. DESIGN Uncontrolled before-after intervention cluster trial. SETTINGS/PARTICIPANTS The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting). RESULTS An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed. CONCLUSIONS These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.
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Affiliation(s)
- Massimo Costantini
- 1Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
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McCourt R, James Power J, Glackin M. General nurses' experiences of end-of-life care in the acute hospital setting: a literature review. Int J Palliat Nurs 2013; 19:510-6. [PMID: 24162282 DOI: 10.12968/ijpn.2013.19.10.510] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Approximately 90% of the UK population spend some time in hospital in their final year of life, and more than half of the population die in hospital. This review aims to explore the experiences of general nurses when providing end-of-life care to patients in the acute hospital setting. Nine studies were identified through a literature search, and each was then analysed and evaluated until themes emerged. Six themes were drawn from the literature: lack of education and knowledge, lack of time with patients, barriers arising in the culture of the health-care setting, communication barriers, symptom management, and nurses' personal issues. The themes cause concern about the quality of end-of-life care being provided in the acute care setting. The literature appears to be consistent in the view that terminally ill patients are best cared for in specialised care settings, such as palliative care units and hospices. However, increasing demands on health services will result in greater numbers of dying patients being admitted to the acute hospital setting. It is therefore paramount that general nurses' educational needs are met to ensure they develop clinical competence to provide high-quality holistic end-of-life care.
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The last three days of life: a comparison of symptoms in hospitalised cancer and non-cancer patients using the resident assessment instrument for palliative care. J Geriatr Oncol 2013. [DOI: 10.1016/j.jgo.2013.09.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Donnelly S, Dickson M. Relatives' matched with staff's experience of the moment of death in a tertiary referral hospital. QJM 2013; 106:731-6. [PMID: 23613596 DOI: 10.1093/qjmed/hct095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although the majority of deaths occur in hospital it has been suggested that dying in hospital is largely a negative experience. AIM To explore the experience of relatives and staff of patients dying in hospital using qualitative grounded theory. METHODS Patients receiving palliative care were identified who were likely to die in hospital. Family members were met by the researcher prior to the patient's death. The ward nurse and doctor (excluding palliative care team) most involved at that time were interviewed within 48 h of the death. The family were interviewed 2 weeks later. Interviewees described their experience of the patient's dying and death. Recruitment and thematic analysis of interviews occurred concurrently. RESULTS Twelve triads over 6 months (relative, nurse and doctor) were interviewed in relation to 12 patients. Dying patients and families need a guide to attend to their needs. Every detail is remembered by the family who take up residence in the hospital. Families value acts of kindness by staff. Hospital may offer benefits for the dying patient and family. However, there are gaps in care identified by families and staff. After death is critical time for the family. Junior doctors are often uncertain of their role, expressing grief and guilt. Young nurses inexperienced in care of dying patients value support and guidance by senior colleagues. CONCLUSION Leadership from nursing and medical staff is required for seamless provision of competent and compassionate care at this life changing time for grieving families.
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Affiliation(s)
- S Donnelly
- Palliative Medicine Department, Wellington Public Hospital, Private Bag 7902, Wellington 6242, New Zealand.
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36
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Toscani F, Di Giulio P, Villani D, Giunco F, Brunelli C, Gentile S, Finetti S, Charrier L, Monti M, van der Steen, on behalf of the End JT. Treatments and Prescriptions in Advanced Dementia Patients Residing in Long-Term Care Institutions and at Home. J Palliat Med 2013; 16:31-7. [DOI: 10.1089/jpm.2012.0165] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franco Toscani
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
| | - Paola Di Giulio
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
- Department of Public Health and Microbiology, Faculty of Medicine and Surgery, University of Turin, Turin, and Mario Negri Institute, Milan, Italy
| | - Daniele Villani
- Neuro-rehabilitation and Alzheimer's Disease Evaluation Unit, “Figlie di San Camillo” Hospital, Cremona, Italy
| | - Fabrizio Giunco
- Geriatric Polifunctional Center S. Pietro of Monza, Monza, Italy
| | - Cinzia Brunelli
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
| | - Simona Gentile
- Rehabilitation and Alzheimer's Disease Evaluation Unit, Ancelle della Carità Hospital, Cremona, Italy
| | - Silvia Finetti
- Lino Maestroni Foundation, Palliative Medicine Research Institute, Cremona, Italy
| | - Lorena Charrier
- Department of Public Health and Microbiology, Faculty of Medicine and Surgery, University of Turin, Turin, Italy
| | - Massimo Monti
- Geriatric Institute “Pio Albergo Trivulzio,” Milan, Italy
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Buone cure di fine vita in ospedale. Un obiettivo possibile e necessario. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2011.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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38
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Cure di fine vita nei pazienti oncologici terminali in Medicina Interna. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2011.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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39
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Meñaca A, Evans N, Andrew EV, Toscani F, Finetti S, Gómez-Batiste X, Higginson IJ, Harding R, Pool R, Gysels M. End-of-life care across Southern Europe: A critical review of cultural similarities and differences between Italy, Spain and Portugal. Crit Rev Oncol Hematol 2012; 82:387-401. [DOI: 10.1016/j.critrevonc.2011.06.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 05/27/2011] [Accepted: 06/09/2011] [Indexed: 12/14/2022] Open
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40
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Gysels M, Evans N, Meñaca A, Andrew E, Toscani F, Finetti S, Pasman HR, Higginson I, Harding R, Pool R. Culture and end of life care: a scoping exercise in seven European countries. PLoS One 2012; 7:e34188. [PMID: 22509278 PMCID: PMC3317929 DOI: 10.1371/journal.pone.0034188] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 02/28/2012] [Indexed: 11/18/2022] Open
Abstract
AIM Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries. METHODS We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes. RESULTS A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities. CONCLUSION This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.
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Affiliation(s)
- Marjolein Gysels
- Barcelona Centre for International Health Research, Universitat de Barcelona, Barcelona, Spain.
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41
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Rocha ASCD, Araújo MPD, Campos A, Costa Filho R, Mesquita ET, Santos MV. Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit. Rev Assoc Med Bras (1992) 2012; 57:529-33. [PMID: 22012286 DOI: 10.1590/s0104-42302011000500010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/11/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS During the study period 700 deaths occurred in the hospital, 211 (30.1%) at the ICU and 88 (12.6%) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38% vs. 21%; p = 0.004). In the ICU, we observed that 21% of the deaths occurred between 6 am and 12 pm, 30% between 12 pm and 6 pm, 26% between 6 pm and 12 am and 24% between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38% of the deaths occurred between 6 am and 12 pm, 18% between 12 pm and 6 pm, 19% between 6 pm and 12 am and 25% between 12 am and 6 am (p = 0.005). CONCLUSION At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.
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Steindal SA, Ranhoff AH, Bredal IS, Sørbye LW, Lerdal A. Last three days of life in the hospital: a comparison of symptoms, signs and treatments in the young old and the oldest old patients using the Resident assessment instrument for palliative care. Int J Older People Nurs 2012; 8:199-206. [PMID: 22329702 DOI: 10.1111/j.1748-3743.2012.00313.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Knowledge concerning the provision of end of life care to the oldest old hospitalised patients is deficient. AIMS AND OBJECTIVES To analyse whether there were differences in registered nurses' documentation of the young old vs. the oldest old patients according to symptoms, clinical signs and treatment in the last 3 days of life. DESIGN Data were collected retrospectively in a cross-sectional comparative study at a hospital between autumn 2007 and spring 2009. Methods. The study included 190 patients: 101 (65-84 years) and 89 (85+). Data were extracted from the patients' electronic records using the Resident Assessment Instrument for Palliative Care (RAI-PC). RESULTS Falls (OR = 4.01, 95% CI 1.47-10.90) and peripheral oedema (OR = 2.74, 95% CI 1.06-7.11) were significantly more frequent documented in the oldest old patients compared with the young old patients. Delirium was recorded in 15.3% of all patients. CONCLUSION With the exception of more falls and peripheral oedema in the oldest old patients, this study showed no differences in symptoms and treatment between the young old and the oldest old patients. Delirium was poorly documented compared to other studies. Implications for practice. The oldest old patients have a higher risk of falls in the final phase of life, and fall prevention should be considered.
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Affiliation(s)
- Simen A Steindal
- Diakonhjemmet University College, Institute of Nursing and Health, Oslo, Norway.
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Quality of end-of-life care for patients with metastatic non-small-cell lung cancer in general wards and palliative care units in Japan. Support Care Cancer 2012; 20:883-8. [PMID: 22246597 DOI: 10.1007/s00520-011-1374-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 12/29/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Patients with lung cancer in Japan often receive aggressive care near the end of life and die in an acute care hospital. We describe the differences in end-of-life care for metastatic non-small-cell lung cancer (NSCLC) patients between general wards and a palliative care unit (PCU). METHODS A retrospective analysis was conducted using data from patients who received at least second-line chemotherapy between 2002 and 2007 in a single institute. Among 72 eligible patients, we categorised patients into two groups, those who died in general wards (n = 57) and those who died in the PCU (n = 15), and examined end-of-life care including chemotherapy, do-not-resuscitate (DNR) decision making and treatment in the last 48 h of life. RESULTS Mean number of days between the last chemotherapy and death was shorter in general wards than in the PCU (P = 0.019). Furthermore, 25% of patients in general wards received chemotherapy within the last 2 weeks of life. Rates of multiple hospitalisations in the last month of life appeared higher in general wards than in the PCU. Mean number of days between documentation of DNR and death was shorter in general wards than in the PCU (P = 0.0010). Patients in general wards received a greater volume of hydration than those in the PCU (P < 0.001). CONCLUSIONS Patients with metastatic NSCLC in general wards receive inappropriate care near the end of life. Further studies are needed to develop interventions for making decisions regarding end-of-life care.
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Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit. Rev Assoc Med Bras (1992) 2011. [DOI: 10.1016/s0104-4230(11)70106-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Di Leo S, Beccaro M, Finelli S, Borreani C, Costantini M. Expectations about and impact of the Liverpool Care Pathway for the dying patient in an Italian hospital. Palliat Med 2011; 25:293-303. [PMID: 21239466 DOI: 10.1177/0269216310392436] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study is aimed at exploring the expectations about and the impact on healthcare staff of the Liverpool Care Pathway for the dying patient (LCP) in an Italian hospital. Qualitative information was derived from four focus group (FG) meetings that were carried out separately by profession and scheduled before the beginning and after the end of the implementation process of the Italian version of LCP for hospitals (LCP-I). Interview topics concerned end-of-life care related problems and expectations about the impact of the LCP-I programme. Tape recordings of the FGs were transcribed verbatim, and transcripts analysed independently by two research psychologists using thematic analysis. Five major topics were identified: managing pain and discontinuing inappropriate treatments, communicating with patients, communicating with relatives, communicating between professionals and practical issues. As compared with those reported in the initial FGs, responses from the final FGs highlighted that physicians felt more confident with pain management and with discontinuing inappropriate treatment, and were more inclined to recognize the value of the nurses' work. Nurses underlined advantages in using pro re nata medication, but stressed lack of personnel and time as obstacles in consistent improvement of end-of-life care. All participants seemed to acquire greater awareness of their difficulties in communication and, paradoxically, became more uncertain of their ability to liaise with dying patients and their families. LCP-I implementation may improve both knowledge about physical symptom management and professional awareness of the problems related to emotional and informative support in end-of-life care.
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Affiliation(s)
- Silvia Di Leo
- Regional Palliative Care Network National Cancer Research Institute, Largo R. Benzi 10, 16132 Genoa, Italy.
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Steindal SA, Bredal IS, Sørbye LW, Lerdal A. Pain control at the end of life: a comparative study of hospitalized cancer and noncancer patients. Scand J Caring Sci 2011; 25:771-9. [DOI: 10.1111/j.1471-6712.2011.00892.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Alonso-Babarro A, Bruera E, Varela-Cerdeira M, Boya-Cristia MJ, Madero R, Torres-Vigil I, De Castro J, González-Barón M. Can this patient be discharged home? Factors associated with at-home death among patients with cancer. J Clin Oncol 2011; 29:1159-67. [PMID: 21343566 DOI: 10.1200/jco.2010.31.6752] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The purpose of this study was to identify factors associated with at-home death among patients with advanced cancer and create a decision-making model for discharging patients from an acute-care hospital. PATIENTS AND METHODS We conducted an observational cohort study to identify the association between place of death and the clinical and demographic characteristics of patients with advanced cancer who received care from a palliative home care team (PHCT) and of their primary caregivers. We used logistic regression analysis to identify the predictors of at-home death. RESULTS We identified 380 patients who met the study inclusion criteria; of these, 245 patients (64%) died at home, 72 (19%) died in an acute-care hospital, 60 (16%) died in a palliative care unit, and three (1%) died in a nursing home. Median follow-up was 48 days. We included the 16 variables that were significant in univariate analysis in our decision-making model. Five variables predictive of at-home death were retained in the multivariate analysis: caregiver's preferred place of death, patients' preferred place of death, caregiver's perceived social support, number of hospital admission days, and number of PHCT visits. A subsequent reduced model including only those variables that were known at the time of discharge (caregivers' preferred place of death, patients' preferred place of death, and caregivers' perceived social support) had a sensitivity of 96% and a specificity of 81% in predicting place of death. CONCLUSION Asking a few simple patient- and family-centered questions may help to inform the decision regarding the best place for end-of-life care and death.
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Costantini M, Ottonelli S, Canavacci L, Pellegrini F, Beccaro M. The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial. BMC Health Serv Res 2011; 11:13. [PMID: 21261949 PMCID: PMC3040703 DOI: 10.1186/1472-6963-11-13] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 01/24/2011] [Indexed: 11/29/2022] Open
Abstract
Background Most cancer patients still die in hospital, mainly in medical wards. Many studies in different countries have shown the poor quality of end-of-life care delivery in hospitals. The Program "Liverpool Care Pathway for the dying patient" (LCP), developed in the UK to transfer the hospice model of care into hospitals and other care settings, is a complex intervention to improve the quality of end-of-life care. The results from qualitative and quantitative studies suggest that the LCP Program can improve significantly the quality of end-of-life care delivery in hospitals, but no randomised trial has been conducted till now. Methods and design This is a randomized cluster trial, stratified by regions and matched for assessment period. Pairs of eligible medical wards from different hospitals will be randomized to receive the LCP-I Program or no intervention until the end of the trial. The LCP-I Program will be implemented by a Palliative Care Unit. The assessment of the end-points will be performed for all cancer deaths occurred in the six months after the end of the LCP-I implementation in the experimental wards and, in the same period of time, in the matched control wards. The primary end-point is the overall quality of end-of-life care provided on the ward to dying cancer patients and their families, assessed using the Global Scale of the Italian version of the Toolkit "After-death Bereaved Family Member Interview". Discussion This study can be interpreted as a Phase III trial according to the Medical Research Council Framework. In this study, the effectiveness of a fully defined intervention is assessed by comparing the distribution of the endpoints in the experimental and in the control arm. Research ID RFPS-2006-6-341619 Trial registration ClinicalTrials.gov Identifier: NCT01081899
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Affiliation(s)
- Massimo Costantini
- Regional Palliative Care Network, National Cancer Research Institute, Genoa, Italy.
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Beccaro M, Caraceni A, Costantini M. End-of-life care in Italian hospitals: quality of and satisfaction with care from the caregivers' point of view--results from the Italian Survey of the Dying of Cancer. J Pain Symptom Manage 2010; 39:1003-15. [PMID: 20538184 DOI: 10.1016/j.jpainsymman.2009.11.317] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 10/14/2009] [Accepted: 11/05/2009] [Indexed: 11/20/2022]
Abstract
CONTEXT A number of studies have highlighted the poor quality of end-of-life (EOL) care provided in hospital settings, leading to a reduction in the quality of EOL care and increase in patient and caregiver dissatisfaction levels. OBJECTIVES The aims of this study were the evaluation of the prevalence of major symptoms, treatment, outcomes, information, and care provided to dying cancer patients in Italian hospitals; and an analysis of clinical and socio-demographic factors associated with caregiver satisfaction with the health care provided. METHODS This is a mortality follow-back survey of 2,000 cancer deaths representative of the country. Caregivers were interviewed about patients' experiences by using a tailored version of the View of Informal Carers-Evaluation of Services questionnaire. RESULTS Valid interviews were obtained for 84% (n=364) of the cancer patients who died in hospital. Most Italian cancer patients dying in hospital suffered from a number of untreated or poorly treated symptoms, and only a few reported an acceptable control over physical suffering. Moreover, only two-thirds of patients and one-third of caregivers received basic information on therapies and care. About one-third of the caregivers expressed dissatisfaction with the health care received. The probability of being satisfied was more likely for caregivers of patients living in the north of Italy; caregivers of patients who had not experienced or were only slightly distressed by fatigue; and caregivers who were generally satisfied with hospital facilities and when the health care professionals had provided appropriate information to both patients and caregivers. CONCLUSION This study revealed poor quality of EOL care in Italian hospitals, with almost one-third of the caregivers expressing their clear dissatisfaction. A national policy is, therefore, urgently called for to improve the quality of EOL care in Italian hospitals.
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Affiliation(s)
- Monica Beccaro
- Regional Palliative Care Network, National Cancer Research Institute, 16132 Genoa, Italy.
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Moyano J, Zambrano S, Mayungo T. Characteristics of the last hospital stay in terminal patients at an acute care hospital in Colombia. Am J Hosp Palliat Care 2010; 27:402-6. [PMID: 20360598 DOI: 10.1177/1049909110362522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED In Colombia, most palliative care is provided in acute care hospitals. In those settings, a palliative care approach could be limited because of a disease-oriented approach instead of patient-centered care. PURPOSE To know the framework of a typical Colombian university hospital that provides palliative care services. MATERIAL AND METHODS In a retrospective manner, the medical records of deceased patients during 2006 were revisited. RESULTS Most patients were not treated by palliative care specialists, so curative-oriented treatment were common among these patients. CONCLUSION In acute hospitals, palliative care teams should participate in the care of patients at the start of treatment.
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Affiliation(s)
- Jairo Moyano
- Anaesthesia Department, Pain Clinic, Fundación Santafé de Bogotá, Bogotá, Colombia.
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