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Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study. J Gen Intern Med 2021; 36:3689-3696. [PMID: 34047924 PMCID: PMC8642498 DOI: 10.1007/s11606-021-06780-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There has been a reduction in BZD prescribing in the Veterans Affairs (VA) health care system since 2013. It is unknown whether the decline in VA-dispensed BZDs has been offset by Medicare Part D prescriptions. OBJECTIVES To examine (1) whether, accounting for Part D, declines in BZD prescribing to older Veterans remain; (2) patient characteristics associated with obtaining BZDs outside VA and facility variation in BZD source (VA only, VA and Part D, Part D only). DESIGN Retrospective cohort study with mixed effects multinomial logistic model examining characteristics associated with BZD source. PATIENTS A total of 1,746,278 Veterans aged ≥65 enrolled in VA and Part D, 2013-2017. MAIN MEASURES BZD prescription prevalence and source. KEY RESULTS From January 2013 to June 2017, the quarterly prevalence of older Veterans with Part D filling BZD prescriptions through the VA declined from 5.2 to 3.1% (p<0.001) or, accounting for Part D, from 10.0 to 7.7% (p<0.001). Among those prescribed BZDs between July 2016 and June 2017, 37.0%, 10.2%, and 52.8% received prescriptions from VA only, both VA and Part D, or Part D only, respectively. Older age was associated with higher odds of obtaining BZDs through Part D (e.g., compared to those 65-74, Veterans ≥85 had adjusted odds ratio [AOR] for Part D vs. VA only of 1.8 [95% highest posterior density interval (HPDI), 1.69, 1.86]). Veterans with substance use disorders accounted for few BZD prescriptions from any source but were associated with higher odds of prescriptions through Part D (e.g., alcohol use disorder AOR for Part D vs. VA alone: 1.9 [95% HPDI, 1.63, 2.11]) CONCLUSIONS: The decline in BZD use by older Veterans with Part D coverage remained after accounting for Part D, but the majority of BZD prescriptions came from Medicare. Further reducing BZD prescribing to older Veterans should consider prescriptions from community sources.
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Beaussant Y, Sanders J, Sager Z, Tulsky JA, Braun IM, Blinderman CD, Bossis AP, Byock I. Defining the Roles and Research Priorities for Psychedelic-Assisted Therapies in Patients with Serious Illness: Expert Clinicians' and Investigators' Perspectives. J Palliat Med 2020; 23:1323-1334. [PMID: 32233936 DOI: 10.1089/jpm.2019.0603] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Recent and preprohibition studies show that patients with serious illness might benefit from psychedelic-assisted therapies for a range of symptoms, physical, psychosocial, and existential. Objective: To explore the potential roles and research priorities of these therapies in patients with serious illness. Design, Setting, and Participants: Qualitative study based on semistructured interviews with 17 experts in serious illness care and/or psychedelic research from the United States and Canada. Measurements: The interview guide elicited participants' perspectives on (1) the potential roles of psychedelic-assisted therapies in this setting, (2) research priorities relevant to this population, and (3) the potential for integrating psychedelic-assisted therapies into existing delivery models of serious illness care. We used thematic analysis until thematic saturation. Results: Domain I: Participants had polar views on the therapeutic potential of psychedelic-assisted therapies, ranging from strong beliefs in their medical utility to reluctance about their use in this patient population. They shared concerns related to the risks of adverse effects, such as delirium or worsening of psychological distress. Domain II: Research priorities primarily concerned patients with clinically diagnosed psychosocial distress, such as depression, anxiety, or demoralization. Participants also articulated potential roles extending beyond traditional medical diagnosis. Domain III: Participants emphasized essential safety and efficacy guidelines relevant to the integration of these therapies into existing models of care. Conclusion: This qualitative study highlights issues and priorities for research on psychedelic-assisted therapies in patients with serious illness and proposes a conceptual framework for integrating these therapies into existing delivery models of serious illness care.
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Affiliation(s)
- Yvan Beaussant
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,California Institute of Integral Studies, San Francisco, California, USA
| | - Justin Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zachary Sager
- New England Geriatric Research, Education, and Clinical Center, Division of Geriatrics and Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ilana M Braun
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Craig D Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Anthony P Bossis
- Department of Psychiatry, New York University School of Medicine, New York, New York, USA
| | - Ira Byock
- Institute for Human Caring, Providence St. Joseph Health, Torrance, California, USA.,Department of Medicine and Community & Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Kozlov E, Eghan C, Moran S, Herr K, Reid MC. Palliative Care Providers' Practices Surrounding Psychological Distress Screening and Treatment: A National Survey. Am J Hosp Palliat Care 2018; 35:938-944. [PMID: 29212346 PMCID: PMC5786500 DOI: 10.1177/1049909117743960] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To investigate how inpatient palliative care teams nationwide currently screen for and treat psychological distress. METHODS A web-based survey was sent to inpatient palliative care providers of all disciplines nationwide asking about their practice patterns regarding psychological assessment and treatment. Descriptive statistics were used to characterize the sample and responses, and analysis of variance was conducted to determine whether certain disciplines were more likely to utilize specific treatment modalities. RESULTS A total of N = 236 respondents were included in the final analyses. Providers reported that they encounter psychological distress regularly in their practice and that they screen for distress using multiple methods. When psychological distress is detected, providers reported referring patients to an average of 3 different providers (standard deviation = 1.46), most frequently a social worker (69.6%) or chaplain (65.3%) on the palliative care team. A total of 84.6% of physicians and 54.5% of nurse practitioners reported that they prescribe anxiolytics or selective serotonin reuptake inhibitors to patients experiencing psychological distress. DISCUSSION AND CONCLUSIONS This study revealed significant variability and redundancy in how palliative care teams currently manage psychological distress. The lack of consistency potentially stems from the variability in the composition of palliative care teams across care settings and the lack of scientific evidence for best practices in psychological care in palliative care. Future research is needed to establish best practices in the screening and treatment of psychological distress for patients receiving palliative care.
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Affiliation(s)
- Elissa Kozlov
- Division of Geriatric and Palliative Medicine, New York–Presbyterian Hospital/Weill Cornell Medicine, New York City, NY, USA
| | - Claude Eghan
- Division of Geriatric and Palliative Medicine, New York–Presbyterian Hospital/Weill Cornell Medicine, New York City, NY, USA
| | - Sheila Moran
- Division of Geriatric and Palliative Medicine, New York–Presbyterian Hospital/Weill Cornell Medicine, New York City, NY, USA
| | - Keela Herr
- Division of Geriatric and Palliative Medicine, New York–Presbyterian Hospital/Weill Cornell Medicine, New York City, NY, USA
| | - M. Carrington Reid
- Division of Geriatric and Palliative Medicine, New York–Presbyterian Hospital/Weill Cornell Medicine, New York City, NY, USA
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Pruskowski J, Rosielle DA, Pontiff L, Reitschuler-Cross E. Deprescribing and Tapering Benzodiazepines #355. J Palliat Med 2018; 21:1040-1041. [DOI: 10.1089/jpm.2018.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev 2017; 5:CD004596. [PMID: 28521070 PMCID: PMC6481598 DOI: 10.1002/14651858.cd004596.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2004 (Issue 1) and previously updated in 2012 (Issue 10). Anxiety is common in palliative care patients. It can be a natural response to the complex uncertainty of having a life-limiting illness or impending death, but it may represent a clinically significant issue in its own right. OBJECTIVES To assess the effectiveness of drug therapy for treating symptoms of anxiety in adults with a progressive life-limiting illness who are thought to be in their last year of life. SEARCH METHODS We ran the searches for this update to May 2016. We searched the CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), PsychLIT (Silver Platter) and PsycINFO (Ovid). We searched seven trials registers and seven pharmaceutical industry trials registers. We handsearched the conference abstracts of the European Association of Palliative Care. SELECTION CRITERIA Randomised controlled trials which examined the effect of drug therapy for the treatment of symptoms of anxiety in adult palliative care patients, that is, people with a known progressive life-limiting illness that is no longer responsive to curative treatment, including advanced heart, respiratory and neurological diseases (including dementia). Comparator treatments included placebo; another drug therapy or different dose schedule; or a non-drug intervention such as counselling, cognitive behaviour therapies or relaxation therapies. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts to identify potentially relevant papers for inclusion in the review. We sought full-text reports for all papers retained at this stage and two reviews authors independently assessed these for inclusion in the review. We planned to assess risk of bias and extract data including information on adverse events. We planned to assess the evidence using GRADE and to create a 'Summary of findings' table. MAIN RESULTS In this update, we identified 707 potentially relevant papers and of these we sought the full-text reports of 10 papers. On examination of these full-text reports, we excluded eight and two are awaiting classification as we have insufficient information to make a decision. Thus, in this update, we found no studies which met our inclusion criteria. For the original review, we identified, and then excluded, the full-text reports of six potentially relevant studies. For the 2012 update, we sought, and excluded, two full-text reports. Thus, we found no studies that assessed the effectiveness of drugs to treat symptoms of anxiety in palliative care patients. AUTHORS' CONCLUSIONS There is a lack of evidence to draw a conclusion about the effectiveness of drug therapy for symptoms of anxiety in adult palliative care patients. To date, we have found no studies that meet the inclusion criteria for this review. We are awaiting further information for two studies which may be included in a future update. Randomised controlled trials which assess management of anxiety as a primary endpoint are required to establish the benefits and harms of drug therapy for the treatment of anxiety in palliative care.
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Affiliation(s)
| | | | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
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Kamell A, Smith LK. Attitudes Toward Use of Benzodiazepines among U.S. Hospice Clinicians: Survey and Review of the Literature. J Palliat Med 2016; 19:516-22. [PMID: 27002463 DOI: 10.1089/jpm.2015.0376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Benzodiazepines are commonly used in inpatient hospices internationally. U.S. hospice clinician views toward benzodiazepines are unknown. OBJECTIVES Study objectives were (1) to assess inpatient hospice clinician attitudes towards the benefits of benzodiazepines for various indications and (2) to compare these attitudes to current clinical recommendations and literature. METHODS A survey was developed and distributed to hospices with inpatient units nationwide. Results were analyzed, then compared to current clinical guidelines. Literature review was performed. U.S. hospice physicians and nurses were the study subjects. Participants were asked to indicate their level of agreement regarding benefit from benzodiazepines for various end-of-life symptoms and to answer questions regarding benzodiazepines in delirium. RESULTS Of 143 surveys returned, 128 surveys were completed. For anxiety, 80% of participants agreed that benzodiazepines were beneficial for restlessness, dyspnea 77%, insomnia 68%, dying process 65%, agitation 57%, nausea 54%, hyperactive delirium 42%, and severe pain 38%. Nurses found benzodiazepines beneficial for more indications than physicians. Over 50% reported benzodiazepines on their order sets for agitation, insomnia, acute anxiety, chronic anxiety, chronic panic, restlessness, seizures, and withdrawal. Among physicians, 39% believe that benzodiazepines are overused within their own hospice. A literature review found very limited evidence of overall benefit from benzodiazepines for the symptoms listed above. In addition, this revealed significant evidence for risks and harms from benzodiazepines, particularly in patients at risk for delirium. CONCLUSIONS Benzodiazepines are viewed favorably by most hospice nurses and many hospice physicians for various indications, despite little supportive clinical evidence along with significant potential for harm.
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Hardy J, Randall C, Pinkerton E, Flatley C, Gibbons K, Allan S. A randomised, double-blind controlled trial of intranasal midazolam for the palliation of dyspnoea in patients with life-limiting disease. Support Care Cancer 2016; 24:3069-76. [PMID: 26887587 DOI: 10.1007/s00520-016-3125-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/09/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Anxiety is a major component of breathlessness and is often palliated with benzodiazepines. Midazolam is a short-acting water-soluble benzodiazepine with a rapid onset of action and short half-life. Intranasal midazolam had been shown to be of marked clinical benefit in an uncontrolled pilot study for the control of dyspnoea. A blinded randomised controlled study was therefore undertaken across four Australasian palliative care services. METHODS All participants received six numbered study nasal spray (SNS) bottles, three of which contained midazolam and three placebo. They were instructed to use one SNS bottle on each day they were breathless, for 6 days within 2 weeks. Dyspnoea scores were recorded before and at set time intervals following the first use of each SNS bottle. RESULTS Across all SNS bottles, the maximum change of 2.1 on an 11-point numerical rating scale was seen at 60 min. There was no difference in dyspnoea score between the two arms. Approximately 50 % of participants in each arm had a positive response (i.e. ≥2 point change in dyspnoea score from baseline). Anxiety scores at baseline were low. The most common adverse event was local nasal reactions. CONCLUSION Intranasal midazolam had no clinical benefit over intranasal placebo for the control of dyspnoea. The low level of anxiety at baseline and dose of active drug delivered may have been important factors. Many participants found the SNS bottles to be a challenging mode of drug delivery. This study confirms the importance of placebo-controlled trials for defining best clinical practise.
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Affiliation(s)
- Janet Hardy
- Department of Palliative and Supportive Care, Mater Health Services and Mater Research Institue - University of Queensland, South Brisbane, QLD, Australia.
| | | | - Eve Pinkerton
- Department of Palliative and Supportive Care, Mater Health Services and Mater Research Institue - University of Queensland, South Brisbane, QLD, Australia
| | - Christopher Flatley
- Mater Research Office, Mater Research Institute - University of Queensland, South Brisbane, QLD, Australia
| | - Kristen Gibbons
- Mater Research Office, Mater Research Institute - University of Queensland, South Brisbane, QLD, Australia
| | - Simon Allan
- Arohanui Hospice, Palmerston North, New Zealand
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Younge N, Smith PB, Goldberg RN, Brandon DH, Simmons C, Cotten CM, Bidegain M. Impact of a palliative care program on end-of-life care in a neonatal intensive care unit. J Perinatol 2015; 35:218-22. [PMID: 25341195 PMCID: PMC4491914 DOI: 10.1038/jp.2014.193] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/11/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit. STUDY DESIGN Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education. RESULT Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47). CONCLUSION End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.
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Affiliation(s)
- N Younge
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - P B Smith
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - R N Goldberg
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - D H Brandon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - C Simmons
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - C M Cotten
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - M Bidegain
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Abstract
BACKGROUND Deathbed wills by their nature are susceptible to challenge. Clinicians are frequently invited to give expert opinion about a dying testator's testamentary capacity and/or vulnerability to undue influence either contemporaneously, when the will is made, or retrospectively upon a subsequent challenge, yet there is minimal discourse in this area to assist practice. METHODS The IPA Capacity Taskforce explored the issue of deathbed wills to provide clinicians with an approach to the assessment of testamentary capacity at the end of life. A systematic review searching PubMed and Medline using the terms: "deathbed and wills," "deathbed and testamentary capacity," and "dying and testamentary capacity" yielded one English-language paper. A search of the individual terms "testamentary capacity" and "deathbed" yielded one additional relevant paper. A focused selective review was conducted using these papers and related terms such as "delirium and palliative care." We present two cases to illustrate the key issues here. RESULTS Dying testators are vulnerable to delirium and other physical and psychological comorbidities. Delirium, highly prevalent amongst terminal patients and manifesting as either a hyperactive or hypoactive state, is commonly missed and poorly documented. Whether the person has testamentary capacity depends on whether they satisfy the Banks v Goodfellow legal criteria and whether they are free from undue influence. Regardless of the clinical diagnosis, the ultimate question is can the testator execute a specific will with due consideration to its complexity and the person's circumstances? CONCLUSIONS Dual ethical principles of promoting autonomy of older people with mental disorders whilst protecting them against abuse and exploitation are at stake here. To date, there has been scant discourse in the scientific literature regarding this issue.
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Candy B, Jackson KC, Jones L, Tookman A, King M. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev 2012; 10:CD004596. [PMID: 23076905 DOI: 10.1002/14651858.cd004596.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the review published on 'Drug therapy for anxiety in adult palliative care patients' in Issue 1, 2004 of The Cochrane Library. Anxiety is common in palliative care patients. It can be a natural response to impending death, but it may represent a clinically significant issue in its own right. It may also result from pain, or other untreated or poorly managed symptoms. When anxiety is severe or distressing drug therapy may be considered in addition to supportive care. OBJECTIVES This review aimed to identify and evaluate randomised controlled trials examining the effectiveness of drug therapy for symptoms of anxiety in adult palliative care patients. SEARCH METHODS We searched the following sources: CENTRAL (The Cochrane Library 2012, Issue 2), MEDLINE (1966 to 2012), EMBASE (1980 to 2012), CINAHL (1982 to 2012), PsycLit (1974 to 2000) and PsycInfo (1990 to 2012) for literature pertaining to this topic published in any language using a detailed search strategy. SELECTION CRITERIA We sought prospective, randomised trials, with or without blinding, involving the use of drug therapy for the treatment of symptoms of anxiety in adult palliative care patients. Pharmacological agents included 5-HT3 receptor antagonists, anxiolytic agents, antiepileptic agents, antidepressive agents, antipsychotic agents, benzodiazepines, butyrophenones, phenothiazines, antihistamines, barbiturates, sedative hypnotics, antiepileptic drugs and beta-blockers. DATA COLLECTION AND ANALYSIS We identified and excluded six studies using the original search strategy, with a further two studies being identified and excluded for this 2012 update. We therefore identified a total of eight potential studies but none met the criteria for inclusion in this review. MAIN RESULTS No data were available to enable an assessment to be made of the effectiveness of drugs to treat symptoms of anxiety in palliative care patients. AUTHORS' CONCLUSIONS There remains insufficient evidence to draw a conclusion about the effectiveness of drug therapy for symptoms of anxiety in adult palliative care patients. To date no studies have been found that meet the inclusion criteria for this review. Prospective controlled clinical trials are required in order to establish the benefits and harms of drug therapy for the treatment of anxiety in palliative care.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Unit, UCL Mental Health Sciences Unit, University College Medical School, London, UK.
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Rashidi NM, Zordan RD, Flynn E, Philip JA. The Care of the Very Old in the Last Three Days of Life. J Palliat Med 2011; 14:1339-44. [DOI: 10.1089/jpm.2011.0308] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nadia Mohamad Rashidi
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
| | - Rachel Dolores Zordan
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
| | - Eleanor Flynn
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
- Medical Education Department, The University of Melbourne, Carlton, Victoria, Australia
| | - Jennifer A.M. Philip
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
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Agar M, Currow D, Plummer J, Chye R, Draper B. Differing management of people with advanced cancer and delirium by four sub-specialties. Palliat Med 2008; 22:633-40. [PMID: 18612029 DOI: 10.1177/0269216308088691] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer. METHODS A questionnaire was designed to identify investigations and treatment used, in relation to two cases. RESULTS Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists. INVESTIGATIONS 85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium. TREATMENT Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium. DISCUSSION The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.
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Affiliation(s)
- M Agar
- Sydney South West (western zone) Area Palliative Care Service, Braeside Hospital, Prairiewood, New South Wales, Australia.
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Skurtveit S, Furu K, Bramness JG, Tverdal A. Benzodiazepine use in all alcohol consumers predicts use of opioids in patients 20 years later-a follow-up study of 13 390 men and women aged 40-42 years. Pharmacoepidemiol Drug Saf 2008; 17:926-933. [DOI: 10.1002/pds.1616] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wusthoff CJ, Shellhaas RA, Licht DJ. Management of common neurologic symptoms in pediatric palliative care: seizures, agitation, and spasticity. Pediatr Clin North Am 2007; 54:709-33, xi. [PMID: 17933619 DOI: 10.1016/j.pcl.2007.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Palliative care for children is complex and focuses on patients' comfort. Some of the most troublesome symptoms as patients approach the end of life are seizures, agitation, and spasticity. Many doctors caring for children at the end of life are uncomfortable or untrained in managing these symptoms in children. Our goal is to help physicians recognize and treat these neurologic symptoms optimally.
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Affiliation(s)
- Courtney J Wusthoff
- Division of Child Neurology, The Children's Hospital of Philadelphia, 6th Floor Wood Building, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
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