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Ortega-Chen C, Van Buren N, Kwack J, Mariano JD, Wang SE, Raman C, Cipta A. Palliative Extubation: A Discussion of Practices and Considerations. J Pain Symptom Manage 2023; 66:e219-e231. [PMID: 37023832 DOI: 10.1016/j.jpainsymman.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/27/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.
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Affiliation(s)
- Christina Ortega-Chen
- Department of Geriatrics and Palliative Medicine (COC), Kaiser Permanente Southern California, Panorama City, California, USA.
| | - Nicole Van Buren
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Joseph Kwack
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Jeffrey D Mariano
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
| | - Susan Elizabeth Wang
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Charlene Raman
- Department of Graduate and Medical Education (CR), Kaiser Permanente Southern California Los Angeles Medical Center, Los Angeles, California, USA
| | - Andre Cipta
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
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Obarzanek L, Wu W, Tutag-Lehr V. Opioid Management of Dyspnea at End of Life: A Systematic Review. J Palliat Med 2022; 26:711-726. [PMID: 36453988 DOI: 10.1089/jpm.2022.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this systematic review is to consolidate the existing evidence on opioid use, including administration, dosing, and efficacy, for the relief of dyspnea at end of life. The overarching goal is to optimize clinical management of dyspnea by identifying patterns in opioid use, improving opioid management of dyspnea, and to prioritize future research. Background: Opioids are commonly used in the management of dyspnea at end of life, yet specific administration guidelines are limited. A greater understanding of the effectiveness of opioids in relieving end-of-life dyspnea with consideration of study design, patients, and opioids, including dyspnea evaluation tools and outcomes, will leverage development of standardized administration and dosing. Methods: A PRISMA-guided systematic review using six databases identified quality studies of opioid management for patients with dyspnea at end of life. Results: Twenty-three references met review inclusion criteria, which included terminally ill cancer and noncancer patients with various diagnoses. Studies included two randomized controlled trials, and three nonrandomized experimental, three prospective observational, one cross-sectional, and one case series. Thirteen retrospective chart reviews were also included due to the limited rigorous studies rendered by the search. Thirteen studies evaluated morphine, followed by fentanyl (6), oxycodone (5), general opioid use (4), and hydromorphone (2). Routes of administration were parenteral, oral, combination, and nebulization. Dyspnea was evaluated using self-reporting and non-self-reporting evaluation tools. Sedation was the most reported opioid-related adverse effect. Discussion: Challenges persist in conducting end-of-life research, preventing consensus on standardization of opioid treatment for dyspnea within this specific palliative time frame. Future robust prospective trials using specific, accurate assessment with reassessment of dyspnea/respiratory distress, and consideration of opioid tolerance, polypharmacy, and comorbidities are required.
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Affiliation(s)
| | - Wendy Wu
- Shiffman Medical Library, Wayne State University, Detroit, Michigan, USA
| | - Victoria Tutag-Lehr
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
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Yeh JC, Chae SG, Kennedy PJ, Lien C, Malecha PW, Han HJ, Buss MK, Lee KA. Are Opioid Infusions Used Inappropriately at End of Life? Results From a Quality/Safety Project. J Pain Symptom Manage 2022; 64:e133-e138. [PMID: 35643223 DOI: 10.1016/j.jpainsymman.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/12/2022] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioid continuous infusions are commonly used for end-of-life (EOL) symptoms in hospital settings. However, prescribing practices vary, and even the recent literature contains conflicting protocols and guidelines for best practice. OBJECTIVES To determine the prevalence of potentially inappropriate opioid infusion use for EOL comfort care at an academic medical center, and determine if inappropriate use is associated with distress. METHODS Through literature review and iterative interdisciplinary discussion, we defined three criteria for "potentially inappropriate" infusion use. We conducted a retrospective, observational study of inpatients who died over six months, abstracting demographics, opioid use patterns, survival time, palliative care (PC) involvement, and evidence of patient/caregiver/staff distress from the electronic medical record. RESULTS We identified 193 decedents who received opioid infusions for EOL comfort care. Forty-four percent received opioid infusions that were classified as "potentially inappropriate." Insufficient use of as-needed intravenous opioid boluses and use of opioid infusions in opioid-naïve patients were the most common problems observed. Potentially inappropriate infusions were associated with more frequent patient (24% vs. 2%; P < 0.001) and staff distress (10% vs. 2%; P = 0.02) and were less common when PC provided medication recommendations (20% vs. 50%; P < 0.001). CONCLUSION Potentially inappropriate opioid infusions are prevalent at our hospital, an academic medical center with an active PC team and existing contracts for in-hospital hospice care. Furthermore, potentially inappropriate opioid infusions are associated with increased patient and staff distress. We are developing an interdisciplinary intervention to address this safety issue.
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Affiliation(s)
- Jonathan C Yeh
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Sul Gi Chae
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter J Kennedy
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Lien
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick W Malecha
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Harry J Han
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary K Buss
- Division of Palliative Care (M.K.B.), Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Kathleen A Lee
- Section of Palliative Care, Division of General Medicine and Primary Care (J.C.Y, S.G.C., P.J.K., C.L., P.W.M., H.J.H., K.A.L.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Meesters S, Grüne B, Bausewein C, Schildmann E. "Palliative Syringe Driver"? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care. J Patient Saf 2022; 18:e801-e809. [PMID: 35617602 PMCID: PMC9162073 DOI: 10.1097/pts.0000000000000918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Continuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments. METHODS In a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for "palliative sedation": benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed. RESULTS During the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for "palliative" patients. According to our interviewees' views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an "overall-concept" for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions. CONCLUSIONS Continuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a "standard procedure" in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.
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Affiliation(s)
- Sophie Meesters
- From the Department of Palliative Medicine, LMU Munich, University Hospital, Munich, Germany
| | - Bettina Grüne
- From the Department of Palliative Medicine, LMU Munich, University Hospital, Munich, Germany
| | - Claudia Bausewein
- From the Department of Palliative Medicine, LMU Munich, University Hospital, Munich, Germany
| | - Eva Schildmann
- From the Department of Palliative Medicine, LMU Munich, University Hospital, Munich, Germany
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Awdishu L, Singh RF, Saunders I, Yam FK, Hirsch JD, Lorentz S, Atayee RS, Ma JD, Tsunoda SM, Namba J, Mnatzaganian CL, Painter NA, Watanabe JH, Lee KC, Daniels CD, Morello CM. Advancing Pharmacist Collaborative Care within Academic Health Systems. PHARMACY 2019; 7:pharmacy7040142. [PMID: 31614555 PMCID: PMC6958419 DOI: 10.3390/pharmacy7040142] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/10/2019] [Accepted: 10/05/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction: The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. Summary: We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist–interprofessional teams and (3) physician–pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. Conclusions: The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system.
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Affiliation(s)
- Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Renu F Singh
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Ila Saunders
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Felix K Yam
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA 92093, USA.
| | - Jan D Hirsch
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Irvine School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, CA 92697, USA.
| | - Sarah Lorentz
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
| | - Rabia S Atayee
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Joseph D Ma
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Shirley M Tsunoda
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Jennifer Namba
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Christina L Mnatzaganian
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Nathan A Painter
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Jonathan H Watanabe
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
| | - Kelly C Lee
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Charles D Daniels
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Candis M Morello
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA 92093, USA.
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A Systematic Approach to Comfort Care Transitions in the Emergency Department. J Emerg Med 2018; 56:267-274. [PMID: 30600110 DOI: 10.1016/j.jemermed.2018.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress. OBJECTIVES To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient. METHODS Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients. DISCUSSION Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy. CONCLUSION Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.
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Abstract
This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and CUNY Neuroscience Collaborative, Queens College, City University of New York, Flushing, NY 11367, United States.
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Rady MY, Verheijde JL. The Canadian guidelines for the withdrawal of life-sustaining treatment: the role of evidence. Intensive Care Med 2016; 42:1301-2. [PMID: 27225789 DOI: 10.1007/s00134-016-4372-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Joseph L Verheijde
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
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