1
|
Thomas C, Bruera E, Breitbart W, Alici Y, Blackler L, Kulikowski JD, Sulmasy DP. Reply to: Frailty and ethics at the end of life: The importance of a comprehensive assessment. J Am Geriatr Soc 2024; 72:2885-2887. [PMID: 38838373 DOI: 10.1111/jgs.19024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
This letter comments on the letter by Mazzola et al.
Collapse
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Julia D Kulikowski
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
| |
Collapse
|
2
|
Otani H, Yokomichi N, Imai K, Toyota S, Yamauchi T, Miwa S, Yuasa M, Okamoto S, Kogure T, Inoue S, Morita T. A Novel Objective Measure for Terminal Delirium: Activity Scores Measured by a Sheet-Type Sensor. J Pain Symptom Manage 2024; 68:246-254. [PMID: 38810949 DOI: 10.1016/j.jpainsymman.2024.05.024] [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: 03/28/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
CONTEXT Delirium is a significant concern in end-of-life care. Continuous monitoring of agitation levels using objective methods may have advantages over existing measurement scales. OBJECTIVES To examine whether an objective measure of activity scores measured using a sheet-type non-wearable sensor (Nemuri SCAN [NSCAN]) was correlated with agitation levels measured using the modified Richmond Agitation-Sedation Scale (RASS) in terminally ill patients with cancer. METHODS We conducted a single-center, prospective, observational study in a palliative care unit using the NSCAN to measure activity scores and the RASS to assess agitation levels. RASS scores were prospectively measured by ward nurses blinded to the NSCAN variables. A database was created to pair the RASS scores and activity scores at night on the same day. RESULTS During the observation period, 1209 patients were hospitalized, and 3028 pairs of assessments of 971 patients were analyzed. The NSCAN activity scores significantly increased with increasing RASS scores (Jonckheere-Terpstra test, p < 0.001). The mean values of the activity scores for each RASS score were RASS -5, 28.9; RASS -4, 36.4; RASS -3, 41.7; RASS -2, 57.4; RASS -1, 58.8; RASS 0, 62.6; RASS 1, 79.6; RASS 2, 106.5; and RASS 3, 118.7. CONCLUSION The NSCAN activity significantly correlated with modified RASS agitation scores. Real-time NSCAN data on agitation may aid timely interventions for optimal symptom control. To improve outcomes for patients suffering from terminal delirium, more research on monitoring tools is warranted.
Collapse
Affiliation(s)
- Hiroyuki Otani
- Department of Palliative and Supportive Care(H.O.), St. Mary's Hospital, Kurume City, Fukuoka 830-8543, Japan; Department of Palliative Care Team and Palliative and Supportive Care(H.O.), National Hospital Organization Kyushu Cancer Center, Mitami-ku, Fukuoka 811-1395, Japan.
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division(N.Y., T.M.), Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka 433-8558, Japan
| | - Kengo Imai
- Seirei Hospice(K.I., T.Y., S.M., M.Y.), Seirei Mikatahara General Hospital, Hamamatsu city, Shizuoka 433-8558, Japan
| | - Saori Toyota
- Paramount Bed Sleep Research Laboratory(S.T., T.K.), PARAMOUNT BED CO., Tokyo 136-8670, Japan
| | - Toshihiro Yamauchi
- Seirei Hospice(K.I., T.Y., S.M., M.Y.), Seirei Mikatahara General Hospital, Hamamatsu city, Shizuoka 433-8558, Japan
| | - Satoru Miwa
- Seirei Hospice(K.I., T.Y., S.M., M.Y.), Seirei Mikatahara General Hospital, Hamamatsu city, Shizuoka 433-8558, Japan
| | - Misuzu Yuasa
- Seirei Hospice(K.I., T.Y., S.M., M.Y.), Seirei Mikatahara General Hospital, Hamamatsu city, Shizuoka 433-8558, Japan
| | - Soichiro Okamoto
- Uguisu home clinic(S.O.), Hamamatsu City, Shizuoka Prefecture 430-0856
| | - Takamasa Kogure
- Paramount Bed Sleep Research Laboratory(S.T., T.K.), PARAMOUNT BED CO., Tokyo 136-8670, Japan
| | - Satoshi Inoue
- Clinical Laboratory Department(S.I.), Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka 433-8558, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division(N.Y., T.M.), Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka 433-8558, Japan; Research Association for Community Health(T.M.), Hamamatsu city, Shizuoka 434-0046, Japan
| |
Collapse
|
3
|
Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024; 72:1964-1972. [PMID: 38240387 PMCID: PMC11226357 DOI: 10.1111/jgs.18766] [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] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
Collapse
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
| |
Collapse
|
4
|
Arnold E, Finucane AM, Taylor S, Spiller JA, O’Rourke S, Spenceley J, Carduff E, Tieges Z, MacLullich AMJ. The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study. Palliat Med 2024; 38:535-545. [PMID: 38767241 PMCID: PMC11170929 DOI: 10.1177/02692163241242648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking. AIM To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients. DESIGN A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment. SETTING/PARTICIPANTS Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years. RESULTS A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1). CONCLUSION The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings. TRIAL REGISTRY ISCRTN 97417474.
Collapse
Affiliation(s)
| | - Anne M Finucane
- Marie Curie Hospice Edinburgh, Edinburgh, UK
- Clinical Psychology, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
| | - Alasdair MJ MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
5
|
Kawashima N, Yokomichi N, Morita T, Yabuki R, Hisanaga T, Imai K, Hirose Y, Shimokawa M, Miwa S, Yamauchi T, Okamoto S, Satomi E. Comparison of Pharmacological Treatments for Agitated Delirium in the Last Days of Life. J Pain Symptom Manage 2024; 67:441-452.e3. [PMID: 38355071 DOI: 10.1016/j.jpainsymman.2024.02.008] [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: 12/21/2023] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT Antipsychotics are often used in managing symptoms of terminal delirium, but evidence is limited. OBJECTIVES To explore the comparative effectiveness of haloperidol with as-needed benzodiazepines (HPD) vs. chlorpromazine (CPZ) vs. levomepromazine (LPZ) for agitated delirium in the last days. METHODS A prospective observational study was conducted in two palliative care units in Japan. Adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS-PAL) of one or more were included; palliative care specialist physicians determined that the etiology was irreversible; and estimated survival was 3 weeks or less. Patients treated with HPD, CPZ, or LPZ were analyzed. We measured RASS, NuDESC, Agitation Distress Scale (ADS), and Communication Capacity Scale (CCS) on Days 1 and 3. RESULTS A total of 277 patients were enrolled, and 214 were analyzed (112 in HPD, 50 in CPZ, and 52 in LPZ). In all groups, the mean RASS-PAL score significantly decreased on Day 3 (1.37 to -1.01, 1.87 to -1.04, 1.79 to -0.62, respectively; P < 0.001); the NuDESC and ADS scores also significantly decreased. The percentages of patients with moderate to severe agitation and those with full communication capacity on Day 3 were not significantly different. The treatments were well-tolerated. While one-fourth of HPD group changed antipsychotics, 88% or more of CPZ and LPZ groups continued the initial antipsychotics. CONCLUSION Haloperidol with as-needed benzodiazepine, chlorpromazine, or levomepromazine may be effective and safe for terminal agitation. Chlorpromazine and levomepromazine may have an advantage of no need to change medications.
Collapse
Affiliation(s)
- Natsuki Kawashima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan; Department of Palliative and Supportive Care, University of Tsukuba Hospital, Tsukuba, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan; Research Association for Community Health, Hamamatsu, Japan
| | - Ritsuko Yabuki
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yumi Hirose
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Miho Shimokawa
- Department of Palliative Care, Tsukuba Central Hospital, Ushiku, Japan
| | - Satoru Miwa
- Seirei Hospice, Seirei Miyahara General Hospital, Hamamatsu, Japan
| | | | | | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
6
|
Tang M, Heung Y, Fellman B, Bruera E. Frequency of vaccine hesitancy among patients with advanced cancer. Palliat Support Care 2024; 22:289-295. [PMID: 37525556 DOI: 10.1017/s147895152300113x] [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] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vaccine hesitancy has become prevalent in society. Vulnerable populations, such as those with cancer, are susceptible to increased morbidity and mortality from diseases that may have been prevented through vaccination. OBJECTIVES Our objective was to determine patient perception of vaccine efficacy and safety and sources of information that influence decisions. METHODS This study was a prospective cross-sectional survey trial conducted from March 10, 2022, to November 1, 2022, at a Supportive Care Clinic. Patients completed the survey with a research assistant or from a survey link. Vaccine hesitancy was defined as a response of 2 or more on the Parent Attitudes About Childhood Vaccines (PACV-4). Perception on vaccine safety and efficacy along with the importance of sources of information were determined by a questionnaire. RESULTS Of the 72 patients who completed the PACV-4, 30 were considered vaccine-hesitant (42%). Of those who completed the survey alone (35), 23 (66%) were vaccine-hesitant; and of those who completed the survey with the help of a study coordinator (37), 7 (19%) were vaccine-hesitant. The most important source for decision-making was their doctor (82%, 95% CI 73-89), followed by family (42%, 95% CI 32-52), news/media (31%, 95% CI 22-41), and social media (9%, 95% CI 4-16). Clinical and demographic factors including age, gender, race/ethnicity, education level, and location of residence were not associated with vaccine hesitancy. SIGNIFICANCE OF RESULTS Vaccine hesitancy is present among patients with advanced cancer. The high value given to the doctor's recommendation suggests that universal precautions regarding vaccine recommendation may be an effective intervention.
Collapse
Affiliation(s)
- Michael Tang
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yvonne Heung
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan Fellman
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
7
|
Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Addressing Challenges With Sedation in End-of-Life Care. J Pain Symptom Manage 2024; 67:346-349. [PMID: 38158164 PMCID: PMC10939822 DOI: 10.1016/j.jpainsymman.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.
Collapse
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College (Y.A.), New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine (E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee (L.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA; Departments of Medicine and Philosophy (D.P.S.), Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, District of Columbia, USA
| |
Collapse
|
8
|
Kruize Z, van Campen I, Vermunt L, Geerse O, Stoffels J, Teunissen C, van Zuylen L. Delirium pathophysiology in cancer: neurofilament light chain biomarker - narrative review. BMJ Support Palliat Care 2024:spcare-2024-004781. [PMID: 38290815 DOI: 10.1136/spcare-2024-004781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
Background Delirium is a debilitating disorder with high prevalence near the end of life, impacting quality of life of patients and their relatives. Timely recognition of delirium can lead to prevention and/or better treatment of delirium. According to current hypotheses delirium is thought to result from aberrant inflammation and neurotransmission, with a possible role for neuronal damage. Neurofilament light chain (NfL) is a protein biomarker in body fluids that is unique to neurons, with elevated levels when neurons are damaged, making NfL a viable biomarker for early detection of delirium. This narrative review summarises current research regarding the pathophysiology of delirium and the potential of NfL as a susceptibility biomarker for delirium and places this in the context of care for patients with advanced cancer.Results Six studies were conducted exclusively on NfL in patients with delirium. Three of these studies demonstrated that high plasma NfL levels preoperatively predict delirium in older adult patients postoperatively. Two studies demonstrated that high levels of NfL in intensive care unit (ICU) patients are correlated with delirium duration and severity. One study found that incident delirium in older adult patients was associated with increased median NfL levels during hospitalisation.Conclusions Targeted studies are required to understand if NfL is a susceptibility biomarker for delirium in patients with advanced cancer. In this palliative care context, better accessible matrices, such as saliva or urine, would be helpful for repetitive testing. Improvement of biological measures for delirium can lead to improved early recognition and lay the groundwork for novel therapeutic strategies.
Collapse
Affiliation(s)
- Zita Kruize
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Isa van Campen
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lisa Vermunt
- Department of Laboratory medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Olaf Geerse
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Josephine Stoffels
- Department of Internal Medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Charlotte Teunissen
- Department of Laboratory medicine, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
9
|
MacKenzie J. Giving the terminally ill access to euthanasia is not discriminatory: a response to Reed. JOURNAL OF MEDICAL ETHICS 2024; 50:123. [PMID: 37979972 DOI: 10.1136/jme-2023-109553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/28/2023] [Indexed: 11/20/2023]
|
10
|
Mercadante S. Opioid-induced Neurotoxicity in Patients with Cancer Pain. Curr Treat Options Oncol 2023; 24:1367-1377. [PMID: 37688712 DOI: 10.1007/s11864-023-01117-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 09/11/2023]
Abstract
OPINION STATEMENT Opioid-induced neurotoxicity (OINT) is a neuropsychiatric syndrome observed with opioid therapy. The mechanism of OINT is thought to be multifactorial, and many risk factors may facilitate its development. If symptoms of OINT are seen, the prescriber should consider hydration, discontinuation of the offending opioid drug, or switching of opioid medication, or the use of some adjuvants. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations for opioid switching. Experience and clinical judgment in a specialistic palliative care setting should be used and individual patient characteristics considered when applying any conversion table.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief & Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| |
Collapse
|
11
|
Hsu NC, Huang CC, Hsu CH, Wang TD, Sheng WH. Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study. Cancers (Basel) 2023; 15:3976. [PMID: 37568793 PMCID: PMC10417390 DOI: 10.3390/cancers15153976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/19/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited. METHODS This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed. RESULTS Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs. CONCLUSIONS Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.
Collapse
Affiliation(s)
- Nin-Chieh Hsu
- Division of Hospital Medicine, Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 10051, Taiwan; (N.-C.H.); (T.-D.W.)
- Division of Hospital Medicine, Department of Internal Medicine, Taipei City Hospital Zhongxing Branch, Taipei 103212, Taiwan
| | - Chun-Che Huang
- Department of Healthcare Administration, College of Medicine, I-Shou University, Kaohsiung 84001, Taiwan;
| | - Chia-Hao Hsu
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Tzung-Dau Wang
- Division of Hospital Medicine, Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 10051, Taiwan; (N.-C.H.); (T.-D.W.)
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100229, Taiwan
| | - Wang-Huei Sheng
- College of Medicine, National Taiwan University, Taipei 10051, Taiwan;
| |
Collapse
|
12
|
Libert Y, Choucroun L, Razavi D, Merckaert I. Advance care planning in oncology: a scoping review and some recommendations. Curr Opin Oncol 2023; 35:261-275. [PMID: 37222205 DOI: 10.1097/cco.0000000000000951] [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: 05/25/2023]
Abstract
PURPOSE OF REVIEW Cancer patients' communication with their relatives and healthcare professionals (HCPs) is essential for advance care planning (ACP). The purpose of this scoping review was to synthesize recent research findings about factors enabling cancer patients', their relatives', and physicians' communication about ACP, and to propose recommendations for future ACP implementation in cancer care. RECENT FINDINGS This review confirmed the importance of aspects of the cancer care context (i.e., culture) as ACP uptake-predisposing and -enabling factors. It highlighted the difficulty of determining who should initiate ACP discussion, with which patients and at what time-points. It also highlighted a lack of consideration for socioemotional processes in the study of ACP uptake despite evidence that cancer patients', relatives' and physicians' discomforts that arise from communication about end-of-life and the wish to safeguard each other are main obstacles to ACP implementation. SUMMARY Based on these recent findings, we propose an ACP communication model, developed with the consideration of factors reported to influence ACP uptake and communication in healthcare, and integrating socioemotional processes. The testing of the model may yield suggestions for innovative interventions that can support communication about ACP and promote a better uptake in clinical practice.
Collapse
Affiliation(s)
- Yves Libert
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
| | - Lisa Choucroun
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
| | - Darius Razavi
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
- Centre de Psycho-Oncologie, Brussels, Belgium
| | - Isabelle Merckaert
- Université libre de Bruxelles (ULB), Faculté des Sciences Psychologiques et de l'Éducation
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (H.U.B), Institut Jules Bordet, Service de Psychologie (Secteur Psycho-Oncologie)
- Centre de Psycho-Oncologie, Brussels, Belgium
| |
Collapse
|
13
|
Welsch E, Vashisht A, Stutzman SE, Olson DM. Family Presence May Reduce Postoperative Delirium After Spinal Surgery. J Neurosci Nurs 2023; 55:97-102. [PMID: 37094374 DOI: 10.1097/jnn.0000000000000704] [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: 04/26/2023]
Abstract
ABSTRACT BACKGROUND: Delirium is associated with worse outcomes, but there is a gap in literature identifying nurse-led interventions to reduce delirium in postoperative (postop) surgical spine patients. Because family presence has been associated with a variety of beneficial effects, we aimed to examine whether family presence in the spine intensive care unit (ICU) during the night after surgery was associated with less confusion or delirium on postop day 1. METHODS: This is a prospective nonrandomized pilot clinical trial with pragmatic sampling. Group designation was assigned by natural history. The family-present group was designated as patients for whom a family member remained present during the first night after surgery. The unaccompanied group was designated as patients who did not have a family member stay the night. Data include the Richmond Agitation Sedation Scale, the Confusion Assessment Method for the ICU, the 4AT (Alertness, Attention, Abbreviated mental test, and Acute change) score, and confusion measured with the orientation item on the Glasgow Coma Scale. Baseline data were collected after admission to the spine ICU and compared with the same data collected in the morning of postop day 1. RESULTS: At baseline, 5 of 16 patients in the family-present group (31.3%) had at least 1 incidence of delirium or confusion. Similarly, 6 of 14 patients in the unaccompanied group (42.9%) had at least 1 incidence of delirium or confusion. There was a clinically relevant, but not statistically significant, reduction in postop day 1 delirium or confusion comparing the family-present (6.3%) and unaccompanied (21.4%) groups ( P = .23). CONCLUSION: Family presence may reduce delirium and confusion for patients after spine surgery. The results support continued research into examining nurse-led interventions to reduce delirium and improve outcomes for this population.
Collapse
|
14
|
Martínez-Arnau FM, Puchades-García A, Pérez-Ros P. Accuracy of Delirium Screening Tools in Older People with Cancer-A Systematic Review. Cancers (Basel) 2023; 15:2807. [PMID: 37345143 DOI: 10.3390/cancers15102807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages. OBJECTIVE To determine which delirium screening instrument is the most accurate in older people with cancer. METHODS A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded. RESULTS From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group. CONCLUSIONS Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.
Collapse
Affiliation(s)
- Francisco Miguel Martínez-Arnau
- Department of Physiotherapy, Universitat de València, Gascó Oliag 5, 46010 Valencia, Spain
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
| | - Andrea Puchades-García
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
| | - Pilar Pérez-Ros
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, Menendez Pelayo s/n, 46010 Valencia, Spain
| |
Collapse
|
15
|
Imai K, Morita T, Mori M, Kiuchi D, Yokomichi N, Miwa S, Okamoto S, Yamauchi T, Naito AS, Matsuda Y, Maeda I, Sugano K, Ikenaga M, Inoue S, Satomi E. Visualizing How to Use Antipsychotics for Agitated Delirium in the Last Days of Life. J Pain Symptom Manage 2023; 65:479-489. [PMID: 36682673 DOI: 10.1016/j.jpainsymman.2023.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
CONTEXT How physicians use antipsychotics for agitated delirium in the last days of life varies markedly, which could hamper the quality of care. OBJECTIVES To examine adherence to an algorithm-based treatment for terminal agitated delirium, and explore its effectiveness and safety. METHODS A single-center, prospective, observational study was conducted in a 27-bed palliative care unit in Japan. All adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS) of +1 or more were included; the palliative care specialists determined that the etiology was irreversible, the estimated survival was three weeks or less, and the Eastern Cooperative Oncology Group (ECOG) performance status was three or four. Patients were treated with an algorithm to visualize how to use antipsychotics, with the treatment goal defined as no agitation (RASS≤0) or acceptable agitation for patients and families. We provided all patients nonpharmacological management to alleviate the symptoms of delirium and administered antipsychotic medications when the nonpharmacological approach was insufficient. We measured the adherence rate, RASS, Nursing Delirium Screening Scale items 2, 3, 4 (Nu-DESC), and Agitation Distress Scale item 2 (ADS) on days 0, 1, 3, 7, 14, 21, and 24 hours before death. RESULTS A total of 164 patients were enrolled. Adherence rates were 99, 94, and 89%, and treatment goals were achieved in 66, 83, and 93% on days one, three, and seven, respectively. The mean RASS decreased from +1.41 to -0.84 on day three; Nu-DESC decreased from 4.19 to 1.83, and ADS decreased from 1.54 to 0.38. There were seven severe adverse events (Common Terminology Criteria for Adverse Events (CTCAE) of 3), including aspiration (n = 3), apnea (n = 2), tremor (n = 1), and muscle rigidity (n = 1) on day three. CONCLUSION The algorithm-based treatment could be feasible, effective, and safe. Visualizing how palliative care specialists provide pharmacological management could be beneficial for nonspecialist clinicians, and clinical, educational, and research implications warrant further empirical testing.
Collapse
Affiliation(s)
- Kengo Imai
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan.
| | - Tatsuya Morita
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Daisuke Kiuchi
- Department of Palliative Medicine (D.K., E.S.), National Cancer Center Hospital, Tokyo, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care (T.M., M.M., N.Y.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Satoru Miwa
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | | | - Toshihiro Yamauchi
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care (A.S.N.), Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine (Y.M.), National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Isseki Maeda
- Department of Palliative Care (I.M.), Seri-Chuo Hospital, Toyonaka, Japan
| | - Koji Sugano
- Division of Respiratory Medicine (K.S.), Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Masayuki Ikenaga
- Department of Palliative Medicine (M.I.), Yodogawa Christian Hospital, Osaka, Japan
| | - Satoshi Inoue
- Seirei Hospice (K.I., S.M., T.Y., S.I.), Seirei Miyahara General Hospital, Hamamatsu, Japan
| | - Eriko Satomi
- Department of Palliative Medicine (D.K., E.S.), National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|