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Bombaci A, Di Lorenzo F, Pucci E, Solari A, Veronese S. Education needs in palliative care and advance care planning of Italian residents in neurology: an online survey. Eur J Neurol 2024; 31:e16376. [PMID: 38826082 PMCID: PMC11295156 DOI: 10.1111/ene.16376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 05/16/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND AND PURPOSE Most neurological diseases have a chronic and progressive clinical course, with patients living for extended periods with complex healthcare needs. Evidence from other countries suggests that palliative care (PC) is insufficiently integrated in the care of these patients. This study aims to identify PC and advance care planning (ACP) knowledge and the perceived preparedness of Italian residents in neurology. METHODS This is a cross-sectional online survey of physicians attending the 36 Italian neurology residency programmes. RESULTS Of 854 residents, 188 (22%) participated. Their mean age was 28.4 ± 2.0 years; 49% were women; 45% were from the north, 23% from the centre and 32% from the south of Italy. Few residents (6%) reported that a teaching course in PC was part of the graduate programme, and 3% of the postgraduate programme. During their residency, 9% of participants received PC training, and 18% ACP training. Only 13% reported to have participated in the ACP process, half within their neurology residency programme. Residents considered PC support very/extremely important in all the pre-specified clinical situations, with values ranging between 78% and 96%. Over 70% of residents revealed education needs, particularly concerning ACP. CONCLUSIONS Our data confirm the need for improving PC training in the graduate and postgraduate curriculum. This, together with collaboration and joint training of neurology and PC, is essential to improve the quality and continuity of care and respond to the complex needs of people with neurological disorders causing severe disability.
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Affiliation(s)
- Alessandro Bombaci
- PhD Programme in Neuroscience, ‘Rita Levi Montalcini’ Department of NeuroscienceUniversity of TurinTurinItaly
- Neurology UnitIRCSS Policlinico San DonatoSan Donato MilaneseItaly
- Vita‐Salute San Raffaele UniversityMilanItaly
| | | | | | - Alessandra Solari
- Unit of NeuroepidemiologyFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
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2
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Amadori K, Steiner T. [Palliative neurology]. DER NERVENARZT 2024; 95:743-753. [PMID: 39023548 DOI: 10.1007/s00115-024-01701-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 07/20/2024]
Abstract
Palliative medicine represents the holistic multiprofessional treatment of severely and incurably ill people and their relatives, addressing their complex physical, psychological, social and spiritual needs. The central therapeutic goals are the quality of life and alleviation of suffering. In the course of many neurological diseases, high symptom burden, long and variable trajectories and unfavorable prognosis at times create a need for palliative care even at an early stage, which is currently still inadequately met. This can be countered by qualified neuropalliative care. In addition to intensifying interdisciplinary collaboration, this requires neurologists to have core competencies in palliative care. These include a team-oriented attitude, communication skills, expertise in symptom control and knowledge of biomedical ethics including palliative options at the end of life.
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Affiliation(s)
- K Amadori
- Klinik für Altersmedizin, varisano Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929, Frankfurt am Main, Deutschland.
- Klinik für Neurologie, varisano Klinikum Frankfurt Höchst, Frankfurt am Main, Deutschland.
| | - T Steiner
- Klinik für Neurologie, varisano Klinikum Frankfurt Höchst, Frankfurt am Main, Deutschland
- Klinik für Neurologie, Universitätsklinik Heidelberg, Heidelberg, Deutschland
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3
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Harrigan E, Kirsch HL, Adjepong K, Crooms RC. Pathways to Neuropalliative Care Practice. Semin Neurol 2024. [PMID: 38955220 DOI: 10.1055/s-0044-1787807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
As neuropalliative care is better recognized and more widely utilized, there is as great a need for clinicians trained in the field as there is for disease-specific symptom management, advance care planning, and end-of-life care. In this manuscript, we describe potential career trajectories in neuropalliative care. For clinicians, this includes educational and training opportunities within primary neuropalliative care (integrating palliative care principles into usual neurology practice), specialty neuropalliative care (completing a hospice and palliative medicine fellowship), and hospice. We also describe considerations for establishing new clinical neuropalliative practices and highlight neuropalliative education and research as key areas for advancing the field.
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Affiliation(s)
- Eileen Harrigan
- Department of Neurology, NYU Grossman School of Medicine, New York, New York
| | - Hannah L Kirsch
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Kwame Adjepong
- Department of Neurology, University of California, San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Rita Caroline Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
- Brookdale Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
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Levine M, Bern-Klug M. "They Make the Will, But They Want the Food:" Staff Perspectives on Challenges in Implementing Dementia Advance Directives Related to Stopping Feeding. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024:1-22. [PMID: 38949629 DOI: 10.1080/15524256.2024.2365368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- Meredith Levine
- The Harry and Jeanette Weinberg Center for Elder Justice at the Hebrew Home at Riverdale, Bronx, New York, USA
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Chou CZ, Everett EA, McFarlin J, Ramanathan U. End-of-Life and Hospice Care in Neurologic Diseases. Semin Neurol 2024. [PMID: 38917863 DOI: 10.1055/s-0044-1787809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.
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Affiliation(s)
- Claudia Z Chou
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota
| | - Elyse A Everett
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jessica McFarlin
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Usha Ramanathan
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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6
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Bu J, DeSanto-Madeya S, Lugassy M, Besbris J, Bublitz S, Kramer NM, Gursahani R, Lau W, Kim E, Rhee JY, Paal P. "So we brought these players together": a qualitative study of educators' experiences to analyze the challenges of creating an e-learning program for neuropalliative care. BMC MEDICAL EDUCATION 2024; 24:524. [PMID: 38730447 PMCID: PMC11088003 DOI: 10.1186/s12909-024-05437-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/17/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND In recent years, the subspecialty of neuropalliative care has emerged with the goal of improving the quality of life of patients suffering from neurological disease, though gaps remain in neuropalliative care education and training. E-learning has been described as a way to deliver interactive and facilitated lower-cost learning to address global gaps in medical care. We describe here the development of a novel, international, hybrid, and asynchronous curriculum with both self-paced modules and class-based lectures on neuropalliative care topics designed for the neurologist interested in palliative care, the palliative care physician interested in caring for neurological patients, and any other physician or advanced care providers interested in neuropalliative care. METHODS The course consisted of 12 modules, one per every four weeks, beginning July 2022. Each module is based on a case and relevant topics. Course content was divided into three streams (Neurology Basics, Palliative Care Basics, and Neuropalliative Care Essentials) of which two were optional and one was mandatory, and consisted of classroom sessions, webinars, and an in-person skills session. Evaluation of learners consisted of multiple choice questions and written assignments for each module. Evaluation of the course was based on semi-structured qualitative interviews conducted with both educator and learner, the latter of which will be published separately. Audio files were transcribed and underwent thematic analysis. For the discussion of the results, Khan's e-learning framework was used. RESULTS Ten of the 12 participating educators were interviewed. Of the educators, three identified as mid-career and seven as senior faculty, ranging from six to 33 years of experience. Nine of ten reported an academic affiliation and all reported association with a teaching hospital. Themes identified from the educators' evaluations were: bridging the global gap, getting everybody on board, defining the educational scope, investing extensive hours of voluntary time and resources, benefiting within and beyond the curriculum, understanding the learner's experience, creating a community of shared learning, adapting future teaching and learning strategies, and envisioning long term sustainability. CONCLUSIONS The first year of a novel, international, hybrid, and asynchronous neuropalliative care curriculum has been completed, and its educators have described both successes and avenues for improvement. Further research is planned to assess this curriculum from the learner perspective.
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Affiliation(s)
- Julia Bu
- University of California San Diego, San Diego, CA, USA.
| | | | | | | | - Sarah Bublitz
- Institute of Palliative Care, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Winnie Lau
- University of North Carolina, Chapel Hill, NC, USA
| | - Estella Kim
- University of California, Berkeley, Berkeley, CA, USA
| | - John Y Rhee
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Piret Paal
- Department of Ethnology, Institute of Cultural Studies, University of Tartu, Tartu, Estonia
- Institute of Palliative Care, Paracelsus Medical University, Salzburg, Austria
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Phillips J, Dixon S, Koehler T, Kluger B. Advance Care Planning Among Patients With Amyotrophic Lateral Sclerosis: Patient Perspectives on Goals of Care Conversations. Am J Hosp Palliat Care 2024; 41:295-301. [PMID: 37128837 DOI: 10.1177/10499091231172901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Little is known regarding circumstances surrounding advanced care planning (ACP) for patients with amyotrophic lateral sclerosis (ALS). We aim to describe preferences, and perspectives surrounding ACP in patients with ALS. METHODS We conducted a survey of patients with ALS. Survey questions were related to advance directive completion and ACP discussions regarding end-of-life (EoL) choices. RESULTS 49 surveys were included. Patients have given thought to advance directives, goals of care, and EoL treatments within months of diagnosis (Median: 1 month; IQR: .6 - 3 months). Twenty-seven opened dialogue with spouses, 24 with family members, 19 with health professionals and 16 with their lawyer. Eighty percent were comfortable discussing advance directives and power of attorney while fewer (70%) are less comfortable regarding specific aspects of care such as CPR or invasive ventilation. Only one barrier to discussion was identified with one patient reporting they did not wish to talk about the topic. There was no significant correlation between timing of diagnosis and whether an EoL discussion had occurred (τb = .23, P = .14: n = 42). Level of feeling informed was significantly associated with making EoL decisions for CPR, legal arrangements for a decision maker and completion of living will or AD. CONCLUSION In this small cohort, a substantial proportion of ALS patients initiated EoL conversations early. When feeling informed, patients were more likely to make specific EoL choices. Findings suggest an opportunity for providers to help facilitate conversations, ensuring patient wishes.
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Affiliation(s)
- Joel Phillips
- Department of Neurology, Trinity Health Saint Mary's, Grand Rapids, MI, USA
- Department of Palliative and Supportive Care, Trinity Health Saint Mary's, Grand Rapids, MI, USA
| | - Stacy Dixon
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Benzi Kluger
- Departments of Neurology and Medicine, University of Rochester, Rochester, NY, USA
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Besbris JM, Taylor LP. Palliative Care in Neuro-oncology. Semin Neurol 2024; 44:26-35. [PMID: 38176423 DOI: 10.1055/s-0043-1777703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Historically, the practice of neurology as an independent subspecialty from internal medicine began in Europe and the United States in the 1930s. The American Academy of Neurology (AAN) was founded 75 years ago in 1948, solidifying its emergence as a stand-alone discipline of medicine. In 1967, St. Christopher's Hospice, the first free standing hospice home, was opened in London by Dame Cicely Saunders. Dame Saunders is considered a pioneer in the development of the hospice movement, and she embodies the importance of the multi-disciplinary team in the care of the patient, as she began her career as a nurse, then became a social worker and, finally, a physician. A decade later, in 1978, Dr. Balfour Mount, a Canadian urologic cancer surgeon, coined the term "palliative care" ("to improve the quality of life") after having spent time with Dr. Saunders at St. Christopher's some years earlier. The field of palliative care continued to develop as a distinct subspecialty focused on improving quality of life for patients at any age and in any stage of serious illness. In a 1996 position statement, the AAN made clear that the practice of primary palliative care is the responsibility of all neurologists to their patients. Finally, coming full circle, the specialty of neuro-palliative care, a subspecialty not just of neurology but of palliative medicine, became established around 2018. Neuro-palliative care can be seen as a specialty focusing on the holistic approach to symptom management in patients suffering from neurologic disease with the aim of improved symptom control and attention to the psychologic and spiritual aspects of illness.
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Béreau M, Giffard M, Clairet AL, Degenne G, Tatu L, Richfield E, Magnin E, Vérin M, Auffret M. Terminal Care in Parkinson's Disease: Real-Life Use of Continuous Subcutaneous Apomorphine Infusion to Improve Patient Comfort. JOURNAL OF PARKINSON'S DISEASE 2024; 14:209-219. [PMID: 38217611 PMCID: PMC10836545 DOI: 10.3233/jpd-230201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND There are currently no recommendations on the therapeutic management of Parkinson's disease (PD) patients at the end of life. OBJECTIVE To describe a cohort of patients with PD who benefited from continuous subcutaneous apomorphine infusion (CSAI) initiation at the end of their life as comfort care. METHODS This real-life cohort includes 14 PD patients, who benefited from 24-h, low-dose CSAI (0.5-3 mg/h) in the context of terminal care. Patient's comfort (pain, rigidity, and/or ability to communicate) and occurrence of CSAI-related side-effects (nausea/vomiting, cutaneous and behavioral manifestations) were evaluated based on medical records. RESULTS All patients (age 62-94 years, disease duration 2-32 years) presented with late-stage PD and a compromised oral route. Treatment lasted from a few hours to 39 days. CSAI led to substantial functional improvement, with a good safety profile. Overall clinical comfort was deemed improved by the medical team, the patient, and/or caregivers. CONCLUSIONS CSAI might be a promising approach in PD terminal care, as it reduces motor symptoms and overall discomfort, with an apparent good safety profile. Use of the apomorphine pen, sublingual film or a classic syringe pump might be considered when apomorphine pumps are not available. Larger observational cohorts and randomized controlled trials are needed to establish the efficacy and tolerability of apomorphine in the context of terminal care and more broadly, in an advance care planning perspective.
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Affiliation(s)
- Matthieu Béreau
- Neurology Department, CHU Besançon, Besançon, France
- Université de Franche-Comté, UR LINC, Besançon, France
| | - Mathilde Giffard
- Mobile Palliative Care Team, CHU Besançon, Besançon, France
- Inserm CIC 1431, CHU Besançon, Besançon, France
| | - Anne-Laure Clairet
- Department of Pharmacy, University Hospital of Besançon, Besançon, France
| | | | - Laurent Tatu
- Neurology Clinical Electrophysiology Department, CHU Besançon, Besançon, France
- Laboratoire d’Anatomie, Université de Franche-Comté, Besançon, France
| | - Edward Richfield
- North Bristol NHS Trust, Department of Geriatrics, Southmead Road, Southmead, Bristol, UK
| | - Eloi Magnin
- Neurology Department, CHU Besançon, Besançon, France
- Université de Franche-Comté, UR LINC, Besançon, France
- Centre Neurodéveloppemental ⪡Hors Normes⪢, AFTC, Besançon, France
| | - Marc Vérin
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior & Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital, & University of Rennes, Rennes, France
- Neurology Department, Movement Disorders Unit, Pontchaillou University Hospital, Rennes, France
| | - Manon Auffret
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior & Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital, & University of Rennes, Rennes, France
- France Développement Electronique (FDE), Monswiller, France
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McDarby M, Silverstein HI, Rosa WE, Parker PA, Carpenter BD. Patient and caregiver questions and clinician responses during initial outpatient neuropalliative care appointments. PEC INNOVATION 2023; 3:100207. [PMID: 37700766 PMCID: PMC10494256 DOI: 10.1016/j.pecinn.2023.100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023]
Abstract
Objective Open communication during appointments exemplifies person-centered care. The current study characterized questions asked by persons with neurologic illnesses and their caregivers-and clinicians' responses to those questions-during initial outpatient palliative care appointments. Methods We coded type (direct or indirect) and topic of questions stated by patients and their caregivers in audio recordings from 38 initial outpatient palliative care appointments. We also coded the completeness and quality features of clinicians' responses. Results Patients and caregivers stated 556 total questions; most were direct questions (79.7%) and primarily about symptoms, treatment, and lifestyle issues. Clinicians responded to more than 90% of all questions. Responses to both question types were similar in completeness and quality, but clinicians more frequently offered support in response to direct questions and gave recommendations in response to indirect questions. Conclusion Persons with neurologic illnesses and their caregivers use different question types to obtain information about symptoms and treatment during initial palliative care appointments. Results may guide clinician training and patient education for optimizing information exchange in palliative care. Innovation This study is the first to explore patient and caregiver use of indirect questions in neuropalliative care appointments and the quality of clinicians' responses to those questions.
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Affiliation(s)
- Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Hannah I. Silverstein
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO, United States of America
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Patricia A. Parker
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Brian D. Carpenter
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO, United States of America
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Seshadri S, Dini M, Macchi Z, Auinger P, Norton SA, Holtrop JS, Kluger BM. Reach of Palliative Care for Parkinson Disease: Results From a Large National Survey of Patients and Care Partners. Neurol Clin Pract 2023; 13:e200214. [PMID: 37854173 PMCID: PMC10581080 DOI: 10.1212/cpj.0000000000200214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/15/2023] [Indexed: 10/20/2023]
Abstract
Background and Objectives People with Parkinson disease (PWP) and their care partners have high palliative care needs resulting from disabling motor and nonmotor symptoms. There is growing support for palliative care (PC) approaches to Parkinson disease. However, little is known regarding the extent to which the palliative needs of PWP and care partners are currently being met. This study's primary objective is to describe PWP's and care partners' perceptions of the extent to which their PC needs are being met. Secondary objectives are to describe their perceptions of the quality of clinical communication and their knowledge of PC. Methods PWPs and care partners (n = 12,995) who had consented to receiving surveys from the Parkinson's Foundation were emailed an electronic survey. PC was operationalized as comprising 5 key components: systematic assessment and management of (1) nonmotor symptoms, (2) PWPs' emotional and spiritual needs, (3) care partners' needs, (4) the completion of annual advance care planning, and (5) timely referrals to specialist palliative care and hospice when appropriate. Results A total 1,882 individuals (1,266 PWP and 616 care partners) responded to the survey (response rate 14.5%). Few PWP (22%) reported that their neurologists never asked regarding bothersome nonmotor symptoms or did so or only if they brought it up. Fifty percent of PWP reported that pain as a specific nonmotor symptom was never managed or managed only if they brought it up. Similarly, PWPs' emotional and spiritual needs (55%), care partners' well-being (57%), and completion of advance care planning documentation (79%) were never addressed or only addressed if PWP brought it up. The quality of clinical communication was generally rated as open and honest (64% PWP). Fewer PWP (30%) reported that doctors helped them deal with the uncertainties of Parkinson disease. Most PWP (85%) reported being knowledgeable regarding PC, and 68% reported that the goal of PC was to help friends and family cope with the illness. Discussion Although some elements of PC are currently being addressed in routine care for PWP, there are many gaps and opportunities for improvement. These data may facilitate focused attention and development of resources to improve the quality and availability of PC for Parkinson disease.
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Affiliation(s)
- Sandhya Seshadri
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Megan Dini
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Zachary Macchi
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Peggy Auinger
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Sally A Norton
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Jodi S Holtrop
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
| | - Benzi M Kluger
- Department of Neurology (SS, PA, BMK), University of Rochester; Parkinson's Foundation (MD), New York; Department of Neurology (ZM), University of Colorado Anschutz Medical Campus; Center for Health & Technology (PA), University of Rochester; University of Rochester School of Nursing (SAN), NY; and Department of Family Medicine at the University of Colorado School of Medicine (JSH), Anschutz Medical Campus
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12
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Sharma A. Palliative Care and Care Partner Support in Neuro-oncology. Continuum (Minneap Minn) 2023; 29:1872-1895. [PMID: 38085902 DOI: 10.1212/con.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
ABSTRACT The journey for a patient with a brain tumor and their loved ones can be extremely challenging due to the high burden of physical symptoms and the emotional distress caused by the diagnosis. Optimizing quality of life by addressing symptoms and reducing this emotional distress can improve treatment tolerance and outcomes and alleviate care partner distress and burden. Symptoms in patients with central nervous system (CNS) tumors can vary in onset and intensity, ranging from headaches, seizures, and focal weakness to emotional distress and cognitive dysfunction. Additionally, care partners may demonstrate distress due to the high burden of care and need appropriate support structures and access to resources to alleviate this stress. Evidence-based recommendations are unfortunately limited given the lack of high-quality research in this area, but patients living with CNS tumors and their loved ones can benefit from early and routine symptom identification and management, compassionate and transparent communication, and practical guidance for the future. These principles are part of palliative care, a field of medicine focused on alleviating suffering in patients with serious, chronic illness. Clinicians involved in the care of patients with CNS tumors must be educated in these important primary palliative care principles. This article focuses on key symptom management, strategies for high-quality communication, a discussion of advance care planning, and an overview of end-of-life care.
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13
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Taylor LP, McGranahan TM, Venur VA. Neuro-oncology. Semin Neurol 2023; 43:808-809. [PMID: 38096848 DOI: 10.1055/s-0043-1776767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
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Gursahani R. Neuropalliative Care for India: Who, What, When, Where, Why, How? THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 35:321-324. [PMID: 37167521 DOI: 10.25259/nmji_35_6_321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Roop Gursahani
- Department of Neurology P.D. Hinduja National Hospital Mahim, Mumbai, Maharashtra, India
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15
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Rhee JY, Strander S, Podgurski A, Chiu D, Brizzi K, Forst DA. Palliative Care in Neuro-oncology: an Update. Curr Neurol Neurosci Rep 2023; 23:645-656. [PMID: 37751050 DOI: 10.1007/s11910-023-01301-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE OF REVIEW While the benefits of palliative care for patients with cancer are well established, palliative care in neuro-oncology is still in its early stages. However, in recent years, there has been increasing attention drawn to the need for better palliative care for patients with brain tumors. RECENT FINDINGS There is a growing body of literature demonstrating the high symptom burden and significant supportive care and information needs of these patients and their caregivers. In the area of caregiver needs, the last 3 years has seen a more rapid growth in recognizing and characterizing these needs. However, there remains a knowledge gap regarding the optimal means of addressing these needs. In this article, we outline important recent advances in the literature on palliative care for patients with brain tumors and highlight areas in need of greater attention and investigation.
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Affiliation(s)
- John Y Rhee
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit St, Boston, MA, 02114, USA.
- Department of Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Alyx Podgurski
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit St, Boston, MA, 02114, USA
| | - Daniel Chiu
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit St, Boston, MA, 02114, USA
- Department of Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kate Brizzi
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah A Forst
- Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit St, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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16
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Neylan KD, Miller BL. New Approaches to the Treatment of Frontotemporal Dementia. Neurotherapeutics 2023; 20:1055-1065. [PMID: 37157041 PMCID: PMC10457270 DOI: 10.1007/s13311-023-01380-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/10/2023] Open
Abstract
Frontotemporal dementia (FTD) comprises a diverse group of clinical neurodegenerative syndromes characterized by progressive changes in behavior, personality, executive function, language, and motor function. Approximately 20% of FTD cases have a known genetic cause. The three most common genetic mutations causing FTD are discussed. Frontotemporal lobar degeneration refers to the heterogeneous group of neuropathology underlying FTD clinical syndromes. While there are no current disease-modifying treatments for FTD, management includes off-label pharmacotherapy and non-pharmacological approaches to target symptoms. The utility of several different drug classes is discussed. Medications used in the treatment of Alzheimer's disease have no benefit in FTD and can worsen neuropsychiatric symptoms. Non-pharmacological approaches to management include lifestyle modifications, speech-, occupational-, and physical therapy, peer and caregiver support, and safety considerations. Recent developments in the understanding of the genetics, pathophysiology, neuropathology, and neuroimmunology underlying FTD clinical syndromes have expanded possibilities for disease-modifying and symptom-targeted treatments. Different pathogenetic mechanisms are targeted in several active clinical trials, opening up exciting possibilities for breakthrough advances in treatment and management of FTD spectrum disorders.
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Affiliation(s)
- Kyra D Neylan
- University of California San Francisco Memory and Aging Center, San Francisco, USA.
| | - Bruce L Miller
- University of California San Francisco Memory and Aging Center, San Francisco, USA
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17
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Effects of Palliative Care for Progressive Neurologic Diseases: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2023; 24:171-184. [PMID: 36481217 DOI: 10.1016/j.jamda.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/30/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine the association of palliative care for progressive neurologic diseases with patient- and caregiver-centered outcomes. DESIGN Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies, including pilot studies. SETTING AND PARTICIPANTS Adults with progressive neurologic diseases (dementia, multiple sclerosis, Parkinson's disease, motor neuron disease, multiple system atrophy, and progressive supranuclear palsy) and their caregivers. METHODS MEDLINE, EMBASE, CINAHL PLUS, Cochrane CENTRAL, and PubMed were searched from inception to September 2021. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tools. Narrative synthesis was conducted. Patient quality of life (QoL), symptom burden, caregiver burden, and satisfaction with care were meta-analyzed using a random-effects model. RESULTS Fifteen trials provided data on 3431 patients (mean age, 73.9 years). Compared with usual care, palliative care was statistically significantly associated with lower symptom burden [standardized mean difference (SMD), -0.34 (95% Cl, -0.59 to -0.09)] and higher caregiver satisfaction [SMD, 0.41 (95% Cl, 0.12 to 0.71)] and patient satisfaction [SMD, 0.43 (95% Cl, -0.01 to 0.87)]. However, the associations were not significant after excluding studies with high risk of bias. Insignificant associations of palliative care with caregiver burden [SMD, -0.09 (95% Cl, -0.21 to 0.03)] and patient QoL [SMD, 0.19 (95% Cl, -0.07 to 0.44)] were observed. CONCLUSIONS AND IMPLICATIONS Palliative care is likely to improve symptom burden and satisfaction with care among patients with progressive neurologic diseases and their caregivers, while its effects on QoL and caregiver burden remains inconclusive. Specific intervention components including interdisciplinary team, palliative care physicians, home visits, and spiritual care appeared to be associated with increased effects on improving palliative outcomes. More rigorous designed studies are warranted to examine the effects of neuropalliative care, effective intervention components, optimal timing, and symptom triggers of palliative care referrals.
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Abstract
This Viewpoint advocates for the integration of neuropalliative care as a vital practice for supporting patients with neurological disease and their families.
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Affiliation(s)
- Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Neha M Kramer
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.,Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
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19
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Kramer NM, Besbris J, Hudoba C. Education in neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:259-272. [PMID: 36599512 DOI: 10.1016/b978-0-12-824535-4.00006-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The importance and value of providing palliative care for patients with neurologic disease is increasingly recognized. While palliative and neuropalliative specialists may be well-positioned to provide this care, there is a shortage of specialists to address these needs. As a result, much of the upfront palliative care will naturally be provided by the treating neurologist. It is imperative that all neurologists receive quality training in primary palliative care skills. As the subspecialty of neuropalliative care grows, the need for specialty neuropalliative education has arisen. This chapter reviews existing educational initiatives and common neuropalliative-oriented career tracks and identifies opportunities for growth along the continuum of medical education and beyond.
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Affiliation(s)
- Neha M Kramer
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, United States; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
| | - Jessica Besbris
- Departments of Neurology and Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Hudoba
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, United States
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20
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Harrison KL, Garrett SB, Halim M, Sideman AB, Allison TA, Dohan D, Naasan G, Miller BL, Smith AK, Ritchie CS. “I Didn’t Sign Up for This”: Perspectives from Persons Living with Dementia and Care Partners on Challenges, Supports, and Opportunities to Add Geriatric Neuropalliative Care to Dementia Specialty Care. J Alzheimers Dis 2022; 90:1301-1320. [DOI: 10.3233/jad-220536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In the United States, dementia specialty centers affiliated with centers of excellence for research hold promise as locations to develop innovative, holistic care in care systems otherwise siloed by discipline or payer. Objective: We conducted foundational research to inform development of patient-and family-centered palliative care interventions for dementia specialty centers. Methods: We interviewed persons living with dementia (PLWD), current, and former care partners (CP) recruited from a specialty dementia clinic and purposively selected for variation across disease syndrome and stage. A framework method of thematic analysis included coding, analytic matrices, and pattern mapping. Results: 40 participants included 9 PLWD, 16 current CPs, and 15 former CPs of decedents; 48% impacted by Alzheimer’s disease dementia. While help from family, support groups and adult day centers, paid caregiving, and sensitive clinical care were invaluable to PLWD, CPs, or both, these supports were insufficient to navigate the extensive challenges. Disease-oriented sources of distress included symptoms, functional impairment and falls, uncertainty and loss, and inaccessible care. Social and relational challenges included constrained personal and professional opportunities. The obligation and toll of giving or receiving caregiving were challenging. Clinical care challenges for PLWD and/or CPs included care fragmentation, insufficient guidance to inform planning and need for expert interdisciplinary clinical care at home. Conclusion: Findings highlight the breadth and gravity of gaps, which surpass the disciplinary focus of either behavioral neurology or palliative care alone. Results can inform the development of novel interventions to add principles of geriatrics and neuropalliative care to dementia care.
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Affiliation(s)
- Krista L. Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, CA, USA
| | - Sarah B. Garrett
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Madina Halim
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Alissa Bernstein Sideman
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, CA, USA
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Theresa A. Allison
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Georges Naasan
- The Barbara and Maurice Deane Center for Wellness and Cognitive Health, Department of Neurology, Mount Sinai Hospitals, Icahn School of Medicine, New York, NY, USA
| | - Bruce L. Miller
- Global Brain Health Institute, University of California, San Francisco, CA, USA
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Christine S. Ritchie
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
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21
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Pedrolli C. Reader Response: Clinical Guidance in Neuropalliative Care: An AAN Position Statement. Neurology 2022; 99:541-542. [PMID: 36123136 DOI: 10.1212/wnl.0000000000201216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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22
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Taylor LP. Author Response: Clinical Guidance in Neuropalliative Care: An AAN Position Statement. Neurology 2022; 99:542. [PMID: 36123140 DOI: 10.1212/wnl.0000000000201217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/15/2022] Open
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Rukavina K, Oliver DJ, Guijarro C, Tudor KI, Veronese S, Vanopdenbosch L. Neuropalliative Care in Times of War. Eur J Neurol 2022; 29:3130-3131. [PMID: 35510741 DOI: 10.1111/ene.15383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Katarina Rukavina
- Institute of Psychiatry, Psychology & Neuroscience at King's College London and King's College Hospital NHS Foundation Trust, London, United Kingdom.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, United Kingdom
| | - David J Oliver
- Tizard Centre, University of Kent, Canterbury, United Kingdom
| | - Cristina Guijarro
- Department of Neurology, The HM Sanchinarro University Hospital, Madrid, Spain
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da Silveira MRM, Forte DN. Palliative care and neurology: a path to neuropalliativism. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:328-335. [PMID: 35976309 PMCID: PMC9491435 DOI: 10.1590/0004-282x-anp-2022-s119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
This article aims to expand the understanding of how it is possible to alleviate suffering and enable a dignified life trajectory for patients with progressive neurological diseases or with severe and permanent neurological impairment. The four most common disease trajectories described for people with chronic and progressive disease used to advance care planning, Brazilian normative ethical resolutions, evidence-based benefits of palliative care (PC), as well as particularities of PC in neurology, such as neurological symptom control, caring for existential and psychological suffering, care provider's needs and particularities of pediatric neurologic PC are reviewed.
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Affiliation(s)
- Mariana Ribeiro Marcondes da Silveira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Dor e Cuidados Paliativos, São Paulo SP, Brazil
| | - Daniel Neves Forte
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Emergências Clíncias, São Paulo SP, Brazil
- Hospital Sírio-Libanês, Núcleo de Cuidados Paliativos, São Paulo SP, Brazil
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Gursahani R, Lorenzl S. International models of neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:73-84. [PMID: 36055721 DOI: 10.1016/b978-0-323-85029-2.00012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Can equitable Neuropalliative care (NpC) be delivered globally? This chapter surveys existing services and ground realities in different parts of the world. In many countries, universal healthcare (UHC) seems to have been a precondition for the establishment of palliative care (PC). PC has been recognized as a basic human right as a part of UHC. Quality of Death and PC surveys provide an overview of the existing situation. Currently, PC is largely focused on the needs of cancer patients and this is a legacy issue for professionals and systems. Communities however recognize suffering and do not distinguish between medical diagnoses. The development of NpC as a subspecialty of neurology allows neurologists everywhere to become primary palliative care providers for their own patients. It is also necessary to integrate neurology with existing palliative care services. There is much that can be done to improve NpC provision even within the limits that bound every jurisdiction and trial evidence is emerging to inform this practice. This chapter is a survey of the challenges and the potential.
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Affiliation(s)
- Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India.
| | - Stefan Lorenzl
- Institute of Palliative Care and Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
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