Palliative Sedation: When the Family and Consulting Service See No Alternative

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Pain Management in the Era of the Opioid Crisis

PRACTICAL APPLICATIONS Recognize patients at higher risk for nonmedical opioid use. Learn about screening for chemical coping risk. Diagnose nonmedical opioid use. Manage nonmedical opioid use in the clinical oncology setting. Understand clinical criteria for referral to supportive and palliative care teams.

Cancer-associated malnutrition, cachexia and sarcopenia: the skeleton in the hospital closet 40 years later

An awareness of the importance of nutritional status in hospital settings began more than 40 years ago. Much has been learned since and has altered care. For the past 40 years several large studies have shown that cancer patients are amongst the most malnourished of all patient groups. Recently, the use of gold-standard methods of body composition assessment, including computed tomography, has facilitated the understanding of the true prevalence of cancer cachexia (CC). CC remains a devastating syndrome affecting 50-80 % of cancer patients and it is responsible for the death of at least 20 %. The aetiology is multifactorial and complex; driven by pro-inflammatory cytokines and specific tumour-derived factors, which initiate an energy-intensive acute phase protein response and drive the loss of skeletal muscle even in the presence of adequate food intake and insulin. The most clinically relevant phenotypic feature of CC is muscle loss (sarcopenia), as this relates to asthenia, fatigue, impaired physical function, reduced tolerance to treatments, impaired quality of life and reduced survival. Sarcopenia is present in 20-70 % depending on the tumour type. There is mounting evidence that sarcopenia increases the risk of toxicity to many chemotherapy drugs. However, identification of patients with muscle loss has become increasingly difficult as 40-60 % of cancer patients are overweight or obese, even in the setting of metastatic disease. Further challenges exist in trying to reverse CC and sarcopenia. Future clinical trials investigating dose reductions in sarcopenic patients and dose-escalating studies based on pre-treatment body composition assessment have the potential to alter cancer treatment paradigms.

The Use of Ultrasound in Palliative Care and Hospice

Palliative care aims to reduce symptom burden and enhance quality of life for those with terminal disease. Ultrasound has become an increasingly popular diagnostic and therapeutic modality due to its low cost, ease of portability, safety, and good patient acceptance. A review of the literature to date shows that as a diagnostic tool, as a therapeutic modality, and as a tool to accurately guide palliative procedures, ultrasound can have many roles in palliative care and hospice. Based on our clinical experience, musculoskeletal ultrasound can be of benefit to patients with terminal disease. Examples include adhesive capsulitis in advanced neurologic disease and chronic osteomyelitis in a patient with metastatic colon cancer. Ideally, further studies investigating the use of ultrasound in the palliative care population will be conducted in the future to enhance the availability of diagnostic and therapeutic capabilities of this particular modality.

Musculoskeletal pain in older adults at the end-of-life: a systematic search and critical review of the literature with priorities for future research

Background

Pain is an important issue in end of life care. Although musculoskeletal pain is common in older adults, it is rarely associated with the cause of death and may be overlooked as death approaches. Hence a major target for improving quality of life may be being missed.

Methods

The aim of this study was to systematically search and critically review the literature on musculoskeletal pain at the end of life. Amed, Cinahl, Internurse, Medline, Psych Info, Web of Knowledge and Cochrane review databases were searched for relevant research up to September 2012. The search strategy combined key words expanding the terms ‘palliative’ for population, ‘musculoskeletal’ for exposure, and ‘pain’ for outcome. Predefined inclusion and exclusion criteria were applied.

Results

Five relevant papers and one letter to the editor were found, including case studies and epidemiological research. Current evidence suggests musculoskeletal pain is common in older adults at the end of life and that it can have a substantial impact on individual experience. No information about community based treatment of musculoskeletal pain at the end of life was found.

Conclusion

Priorities for future research include high quality epidemiological studies to establish the prevalence, natural history, impact, assessment, patient priorities and outcomes associated with musculoskeletal pain in the end of life period, and intervention research that provides an evidence base for treatment.

Delirium in palliative medicine: a review

Delirium is a devastating complication of general medical and surgical populations but of particular importance in palliative medicine. It is a clinical syndrome that is often not recognized and, therefore, not treated appropriately. The presence of delirium is a predictor of increased morbidity and mortality, longer hospitalization, and more likely discharge to a nursing facility. This article reviews the pathophysiology, etiology, diagnosis, and treatment of delirium in the palliative medicine population.

Palliative sedation

The focus of palliative care is to relieve human suffering; however, about 90% of patients with advanced cancer will experience severe pain. Intolerable human suffering may be defined in the healthcare setting as symptoms that cannot be tolerated or endured for any length of time. If the patient is unable to communicate, the family or identified decision maker for the patient may decide when symptoms cannot be endured any longer. All dimensions (i.e., physical, psychological, social, emotional, and spiritual) of the symptom causing suffering must be evaluated.