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Imam SN, Braun UK, Garcia MA, Jackson LK. Evolution of Telehealth-Its Impact on Palliative Care and Medication Management. Pharmacy (Basel) 2024; 12:61. [PMID: 38668087 PMCID: PMC11054863 DOI: 10.3390/pharmacy12020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/29/2024] Open
Abstract
Palliative care plays a crucial role in enhancing the quality of life for individuals facing serious illnesses, aiming to alleviate suffering and provide holistic support. With the advent of telehealth, there is a growing interest in leveraging technology to extend the reach and effectiveness of palliative care services. This article provides a comprehensive review of the evolution of telehealth, the current state of telemedicine in palliative care, and the role of telepharmacy and medication management. Herein we highlight the potential benefits, challenges, and future directions of palliative telemedicine. As the field continues to advance, the article proposes key considerations for future research, policy development, and clinical implementation, aiming to maximize the advantages of telehealth in assisting individuals and their families throughout the palliative care journey. The comprehensive analysis presented herein contributes to a deeper understanding of the role of telehealth in palliative care and serves as a guide for shaping its future trajectory.
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Affiliation(s)
- Syed N. Imam
- Office of Connected Care, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA
| | - Ursula K. Braun
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA
| | - Mary A. Garcia
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA
| | - Leanne K. Jackson
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA
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Braun UK, Jackson LK, Garcia MA, Imam SN. A Systematic Review of Naldemedine and Naloxegol for the Treatment of Opioid-Induced Constipation in Cancer Patients. Pharmacy (Basel) 2024; 12:48. [PMID: 38525728 PMCID: PMC10961755 DOI: 10.3390/pharmacy12020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a pervasive and distressing side effect of chronic opioid therapy in patients with cancer pain, significantly impacting their quality of life. Peripherally acting μ-opioid receptor antagonists (PAMORAS) were developed for treatment-resistant OIC but most studies were conducted with non-cancer patients. OBJECTIVE to discuss two oral formulations of PAMORAs, naldemedine and naloxegol, and to review available evidence of the effectiveness of these drugs for OIC in cancer patients. METHODS a comprehensive search to identify primary literature for either naldemedine or naloxegol for OIC in cancer patients. RESULTS Only three prospective randomized, double-blind, placebo-controlled clinical trials for naldemedine enrolling cancer patients were identified; the results of a subgroup analysis of two of those studies and two non-interventional post marketing surveillance studies of these trials are also reported here. For naloxegol, only two randomized controlled trials were identified; both were unsuccessful in enrolling sufficient patients. An additional four prospective non-interventional observational studies with naloxegol were found that enrolled cancer patients. There were significantly higher rates of responders in the PAMORA groups than in the placebo groups. The most common side effect for both PAMORAs was diarrhea. LIMITATIONS All studies were industry-funded, and given that only three trials were randomized controlled studies, the overall quality of the studies was lacking. CONCLUSION Naldemedine or naloxegol appeared safe and useful in the treatment of OIC in cancer patients and may improve their quality of life. Larger-scale randomized placebo-controlled studies of PAMORAs in cancer patients would strengthen existing evidence.
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Affiliation(s)
- Ursula K. Braun
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Leanne K. Jackson
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mary A. Garcia
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; (L.K.J.); (M.A.G.)
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Syed N. Imam
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA;
- Office of Connected Care, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
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Garcia MAG, Imam S, Braun UK, Jackson LK. Rational Prescribing of Pancreatic Enzymes for Patients with Pancreatic Cancer. Pharmacy (Basel) 2024; 12:47. [PMID: 38525727 PMCID: PMC10961774 DOI: 10.3390/pharmacy12020047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
Most patients with pancreatic cancer at some point present with symptoms related to exocrine pancreatic insufficiency (EPI). These include diarrhea, abdominal bloating, indigestion, steatorrhea, weight loss, and anorexia. Even though up to 80% of pancreatic cancer patients eventually present with symptoms related to exocrine pancreatic insufficiency, only 21% are prescribed pancreatic enzyme replacement therapy (PERT). Its effectiveness is also highly dependent on its proper timing of administration, and patients must be thoroughly educated about this. The impact of symptoms of EPI can lead to poorer overall well-being. Pharmacists play a crucial role in properly educating patients on the correct use of pancreatic enzyme replacement therapy. PERT is a key strategy in managing the symptoms of EPI and can improve quality of life, which is a central focus in palliative care. This treatment is profoundly underutilized in the palliative care of these patients. The objective of this review is to discuss the pharmacology, pharmacokinetics, side effects, available evidence of the effectiveness of pancreatic enzyme use for patients with pancreatic cancer, and challenges, along with proposed solutions regarding its use.
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Affiliation(s)
- Mary Acelle G. Garcia
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA; (S.I.); (U.K.B.); (L.K.J.)
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Syed Imam
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA; (S.I.); (U.K.B.); (L.K.J.)
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ursula K. Braun
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA; (S.I.); (U.K.B.); (L.K.J.)
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Leanne K. Jackson
- Rehabilitation & Extended Care Line, Section of Palliative Medicine, Michael E DeBakey Veteran Affairs Medical Center, Houston, TX 77030, USA; (S.I.); (U.K.B.); (L.K.J.)
- Department of Medicine, Section of Geriatric and Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Poon IO, Ajewole V, Braun UK. A Review of Olanzapine in the Treatment of Cancer Anorexia-Cachexia Syndrome. Pharmacy (Basel) 2024; 12:34. [PMID: 38392941 PMCID: PMC10893239 DOI: 10.3390/pharmacy12010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Cancer anorexia-cachexia syndrome (CAS) is a multifactorial condition that is highly prevalent in advanced cancer patients and associated with significant reduction in functional performance, reduction in quality of life, and increased mortality. Currently, no medications are approved for this indication. Recently, the American Society of Clinical Oncology (ASCO) released a rapid recommendation suggesting that low-dose olanzapine once daily may be used to treat cancer cachexia. Many questions still exist on how to use olanzapine for this indication in clinical practice. The objective of this review is to identify existing knowledge on the use of olanzapine for CAS. METHODS A comprehensive search was conducted to identify the primary literature that involved olanzapine for anorexia and cachexia in cancer patients between 2000 and 2023. RESULTS Seven articles were identified and are discussed here, including two randomized double-blinded placebo-controlled studies, one randomized comparative study, two prospective open-label studies, one retrospective chart review, and one case report. CONCLUSIONS Low dose olanzapine (2.5-5 mg once daily) may be useful in the treatment of CAS for increasing appetite, reducing nausea and vomiting, and promoting weight gain. Further large-scale multi-center randomized placebo-controlled studies will be needed to investigate the impact of olanzapine on weight change in CAS patients.
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Affiliation(s)
- Ivy O. Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX 77004, USA; (I.O.P.); (V.A.)
| | - Veronica Ajewole
- Department of Pharmacy Practice, Texas Southern University, Houston, TX 77004, USA; (I.O.P.); (V.A.)
- Pharmacy Department, Houston Methodist Hospital, Houston, TX 77004, USA
| | - Ursula K. Braun
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data report that less than 10% of inpatient palliative teams in the U.S. have a clinical pharmacist. Clinical pharmacists have an impactful role in palliative patients' quality of life by optimizing symptom management, deprescribing, and providing education to the palliative care team as well as patients and their families. In this report, we review the current literature on the role of a palliative pharmacist in an inpatient palliative care setting and compare and contrast this with our own clinical practice, providing case examples about the role of a palliative clinical pharmacist in an interdisciplinary inpatient palliative care setting. Future strategies are needed to increase post-graduate specialized pharmacy residency training in palliative care as well as education on palliative and hospice care in pharmacy schools to support the role of clinical pharmacists in palliative care.
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Affiliation(s)
| | - Ivy O Poon
- Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Pharmacy Practice, Texas Southern University, College of Pharmacy and Health Sciences, Houston, TX, USA
| | - Ursula K Braun
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Hernaez R, Patel A, Jackson LK, Braun UK, Walling AM, Rosen HR. Considerations for Prognosis, Goals of Care, and Specialty Palliative Care for Hospitalized Patients With Acute-on-Chronic Liver Failure. Hepatology 2020; 72:1109-1116. [PMID: 32416642 DOI: 10.1002/hep.31316] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, TX Center, Houston, TX.,VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Division of Gastroenterology and Hepatology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA
| | - Leanne K Jackson
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Ursula K Braun
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Anne M Walling
- Department of Medicine, University of California, Los Angeles, CA.,VA Greater Los Angeles Health System, Los Angeles, CA
| | - Hugo R Rosen
- Department of Medicine, University of Southern California (USC), Los Angeles, CA.,USC Research Center for Liver Diseases, Los Angeles, CA
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Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond. J Am Geriatr Soc 2020; 68:1136-1142. [PMID: 32374440 PMCID: PMC7267615 DOI: 10.1111/jgs.16537] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023]
Abstract
Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as "life-years saved" and "long-term predicted life expectancy" that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136-1142, 2020.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Teneille Brown
- Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leslie Francis
- University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Department of Philosophy, University of Utah, Salt Lake City, Utah, USA
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ramona Rhodes
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.,Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA
| | - Tony Rosen
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Leah J Witt
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Niranjan Thothala
- Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.,Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA
| | - Shan W Liu
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline A Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA
| | - Ursula K Braun
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Debra Saliba
- UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.,VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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Farrell TW, Francis L, Brown T, Ferrante LE, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults. J Am Geriatr Soc 2020; 68:1143-1149. [PMID: 32374466 PMCID: PMC7267288 DOI: 10.1111/jgs.16539] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
Coronavirus disease 2019 (COVID‐19) continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion that disfavors older adults in resource allocation decisions. This is a companion article to the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age‐Related Considerations in the COVID‐19 Era and Beyond.” It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses these issues that informed the development of the AGS positions: (1) age as a determining factor, (2) age as a tiebreaker, (3) criteria with a differential impact on older adults, (4) individual choices and advance directives, (5) racial/ethnic disparities and resource allocation, and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics. J Am Geriatr Soc 68:1143–1149, 2020. See related paper by Farrell et al.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA
| | - Leslie Francis
- University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Department of Philosophy, University of Utah, Salt Lake City, Utah, USA
| | - Teneille Brown
- Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ramona Rhodes
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.,Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA
| | - Tony Rosen
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Leah J Witt
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Niranjan Thothala
- Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.,Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA
| | - Shan W Liu
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline A Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA
| | - Ursula K Braun
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Debra Saliba
- UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.,VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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Rosenberg LJ, Butler JM, Caprio AJ, Rhodes RL, Braun UK, Vitale CA, Telonidis J, Periyakoil VS, Farrell TW. Results From a Survey of American Geriatrics Society Members' Views on Physician‐Assisted Suicide. J Am Geriatr Soc 2019; 68:23-30. [DOI: 10.1111/jgs.16245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa J. Rosenberg
- Southwest Medical Hospice and Palliative Care Las Vegas Nevada
- Roseman University of Health Sciences Henderson Nevada
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal MedicineUniversity of Utah Salt Lake City Utah
- Geriatrics Research Education and Clinical Center, IDEAS HSR&D COINVeterans Affairs Medical Center Salt Lake City Utah
| | - Anthony J. Caprio
- Department of Family MedicineAtrium Health Charlotte North Carolina
- Department of Family MedicineUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Ramona L. Rhodes
- Division of Geriatric Medicine, Department of Internal MedicineUT Southwestern Medical Center Dallas Texas
| | - Ursula K. Braun
- Section of Geriatrics, Department of MedicineBaylor College of Medicine Houston Texas
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical Center Houston Texas
| | - Caroline A. Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal MedicineUniversity of Michigan Ann Arbor Michigan
- Geriatrics Research Education and Clinical CenterVA Ann Arbor Healthcare System Ann Arbor Michigan
| | - Jacqueline Telonidis
- Division of Geriatrics, Department of Internal MedicineUniversity of Utah Salt Lake City Utah
| | - Vyjeyanthi S. Periyakoil
- Stanford University School of Medicine Stanford California
- VA Palo Alto Health Care System Palo Alto California
| | - Timothy W. Farrell
- Division of Geriatrics, Department of Internal MedicineUniversity of Utah Salt Lake City Utah
- VA Salt Lake City Geriatric Research, Education, and Clinical Center Salt Lake City Utah
- University of Utah Health Interprofessional Education Program Salt Lake City Utah
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Arney J, Helm A, Braun UK, Chen GJ, Hayes TG. Barriers and Facilitators to the Use of Genomic-Based Targeted Lung Cancer Therapies in the VA: Qualitative Findings. Fed Pract 2018; 35:S53-S57. [PMID: 30766390 PMCID: PMC6375515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Reflexive testing, standardization of the mutation test ordering procedure and results reporting, and elimination of the preauthorization requirements could facilitate the utilization of targeted therapies.
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Affiliation(s)
- Jennifer Arney
- is a Health Services Researcher, is a Project Coordinator and Health Services Researcher, is the Director of Palliative Care, and is the Chief of Hematology-Oncology Section, all at Michael E. DeBakey VAMC in Houston, Texas. Dr. Braun is an Associate Professor of Medicine and Dr. Hayes is an Associate Professor of Medicine and Program Director of the Hematology-Oncology Fellowship Program, both at Baylor College of Medicine in Houston. is a Professor of Medicine, Division Director in the Division of Health Services Research, and Director in the Office of Scientific, Academic, and Research Mentoring (OSARM), all in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City. Dr. Arney is an Assistant Professor in the Department of Sociology at University of Houston-Clear Lake in Houston
| | - Ashley Helm
- is a Health Services Researcher, is a Project Coordinator and Health Services Researcher, is the Director of Palliative Care, and is the Chief of Hematology-Oncology Section, all at Michael E. DeBakey VAMC in Houston, Texas. Dr. Braun is an Associate Professor of Medicine and Dr. Hayes is an Associate Professor of Medicine and Program Director of the Hematology-Oncology Fellowship Program, both at Baylor College of Medicine in Houston. is a Professor of Medicine, Division Director in the Division of Health Services Research, and Director in the Office of Scientific, Academic, and Research Mentoring (OSARM), all in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City. Dr. Arney is an Assistant Professor in the Department of Sociology at University of Houston-Clear Lake in Houston
| | - Ursula K Braun
- is a Health Services Researcher, is a Project Coordinator and Health Services Researcher, is the Director of Palliative Care, and is the Chief of Hematology-Oncology Section, all at Michael E. DeBakey VAMC in Houston, Texas. Dr. Braun is an Associate Professor of Medicine and Dr. Hayes is an Associate Professor of Medicine and Program Director of the Hematology-Oncology Fellowship Program, both at Baylor College of Medicine in Houston. is a Professor of Medicine, Division Director in the Division of Health Services Research, and Director in the Office of Scientific, Academic, and Research Mentoring (OSARM), all in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City. Dr. Arney is an Assistant Professor in the Department of Sociology at University of Houston-Clear Lake in Houston
| | - G John Chen
- is a Health Services Researcher, is a Project Coordinator and Health Services Researcher, is the Director of Palliative Care, and is the Chief of Hematology-Oncology Section, all at Michael E. DeBakey VAMC in Houston, Texas. Dr. Braun is an Associate Professor of Medicine and Dr. Hayes is an Associate Professor of Medicine and Program Director of the Hematology-Oncology Fellowship Program, both at Baylor College of Medicine in Houston. is a Professor of Medicine, Division Director in the Division of Health Services Research, and Director in the Office of Scientific, Academic, and Research Mentoring (OSARM), all in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City. Dr. Arney is an Assistant Professor in the Department of Sociology at University of Houston-Clear Lake in Houston
| | - Teresa G Hayes
- is a Health Services Researcher, is a Project Coordinator and Health Services Researcher, is the Director of Palliative Care, and is the Chief of Hematology-Oncology Section, all at Michael E. DeBakey VAMC in Houston, Texas. Dr. Braun is an Associate Professor of Medicine and Dr. Hayes is an Associate Professor of Medicine and Program Director of the Hematology-Oncology Fellowship Program, both at Baylor College of Medicine in Houston. is a Professor of Medicine, Division Director in the Division of Health Services Research, and Director in the Office of Scientific, Academic, and Research Mentoring (OSARM), all in the Department of Internal Medicine at the University of Kansas Medical Center in Kansas City. Dr. Arney is an Assistant Professor in the Department of Sociology at University of Houston-Clear Lake in Houston
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11
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Abstract
Opioid analgesia is a mainstay of the treatment of cancer pain. Treatment of pain in patients with cancer with an ongoing substance abuse disorder can be difficult. We report the ethical challenges of treating a patient with cancer with a concomitant substance abuse disorder in an outpatient palliative care setting. We present an analysis of ethical considerations for the palliative care physician and strategies to aid in the successful treatment of such patients. We argue that there are select patients with cancer for whom exclusion from treatment with opioid therapy is warranted if their health is endangered by prescription of these medications.
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Affiliation(s)
- Leanne K. Jackson
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
| | - Syed N. Imam
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
| | - Ursula K. Braun
- Michael E. DeBakey Veterans Affairs Medical Center; Baylor College of Medicine, Houston, TX
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12
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Mody L, Boustani M, Braun UK, Sarkisian C. Evolution of Geriatric Medicine: Midcareer Faculty Continuing the Dialogue. J Am Geriatr Soc 2017; 65:1389-1391. [PMID: 28394479 DOI: 10.1111/jgs.14842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Lona Mody
- Division of Geriatric and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Malaz Boustani
- Indiana University Center for Health Innovation and Implementation Science, Indiana Clinical Translational Institute, Indianapolis, Indiana
| | - Ursula K Braun
- Division of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.,Geriatrics Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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13
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Braun UK, Beyth RJ, Ford ME, Espadas D, McCullough LB. Decision-making styles of seriously ill male Veterans for end-of-life care: Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders. Patient Educ Couns 2014; 94:334-341. [PMID: 24365071 DOI: 10.1016/j.pec.2013.10.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 10/05/2013] [Accepted: 10/26/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To describe self-reported decision-making styles and associated pathways through end-of-life (EOL) decision-making for African-American, Caucasian, and Hispanic seriously ill male Veterans, and to examine potential relationships of race/ethnicity on these styles. METHODS Forty-four African American, White, and Hispanic male Veterans with advanced serious illnesses participated in 8 racially/ethnically homogenous focus groups. Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the racial/ethnic groups. RESULTS Patients described two main decision-making styles, deciding for oneself and letting others decide, leading to five variants that we labeled Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders. These variants, with exception of avoiders (not found among White patients), were found across all racial/ethnic groups. The variants suggested different 'implementation strategies', i.e., how clear patients made decisions and whether or not they then effectively communicated them. CONCLUSION These identified decision-making styles and variants generate strategies for clinicians to better address individualized advance care planning. PRACTICE IMPLICATIONS Physicians should elicit seriously ill patients' decision-making styles and consider potential implementation strategies these styles may generate, thus tailoring individualized recommendations to assist patients in their advance care planning. Patient-centered EOL decision-making can ensure that patient preferences are upheld.
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Affiliation(s)
- Ursula K Braun
- Health Services Research & Development Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, USA; Baylor College of Medicine, Department of Medicine, Section of Geriatrics, Houston, USA.
| | - Rebecca J Beyth
- Geriatric Research Education Clinical Center, NF/SGVHS, Department of Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Marvella E Ford
- Department of Biostatistics, Bioinformatics, and Epidemiology and Cancer Disparities, Hollings Cancer Center, Medical University of South Carolina, Charleston, USA
| | - Donna Espadas
- Health Services Research & Development Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, USA
| | - Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, USA
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14
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Braun UK, Gill AC, Teal CR, Morrison LJ. The utility of reflective writing after a palliative care experience: can we assess medical students' professionalism? J Palliat Med 2013; 16:1342-9. [PMID: 23937062 DOI: 10.1089/jpm.2012.0462] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medical education leaders have called for a curriculum that proactively teaches knowledge, skills, and attitudes required for professional practice and have identified professionalism as a competency domain for medical students. Exposure to palliative care (PC), an often deeply moving clinical experience, is an optimal trigger for rich student reflection, and students' reflective writings can be explored for professional attitudes. OBJECTIVE Our aim was to evaluate the merit of using student reflective writing about a PC clinical experience to teach and assess professionalism. METHODS After a PC patient visit, students wrote a brief reflective essay. We explored qualitatively if/how evidence of students' professionalism was reflected in their writing. Five essays were randomly chosen to develop a preliminary thematic structure, which then guided analysis of 30 additional, randomly chosen essays. Analysts coded transcripts independently, then collaboratively, developed thematic categories, and selected illustrative quotes for each theme and subtheme. RESULTS Essays revealed content reflecting more rich information about students' progress toward achieving two professionalism competencies (demonstrating awareness of one's own perspectives and biases; demonstrating caring, compassion, empathy, and respect) than two others (displaying self-awareness of performance; recognizing and taking actions to correct deficiencies in one's own behavior, knowledge, and skill). CONCLUSIONS Professional attitudes were evident in all essays. The essays had limited use for formal summative assessment of professionalism competencies. However, given the increasing presence of PC clinical experiences at medical schools nationwide, we believe this assessment strategy for professionalism has merit and deserves further investigation.
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Affiliation(s)
- Ursula K Braun
- 1 HSRD Center of Excellence, Michael E. DeBakey VA Medical Center , Houston, Texas
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15
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Abstract
We examined initiation of cholinesterase inhibitors (ChEIs) to determine whether ChEIs were being newly prescribed without sufficient evaluation for dementia and/or delirium and to explore whether there are differences in outcomes, such as mortality, hospital readmission rates, and duration of hospitalization, between patients newly started on ChEI and those who continued such medications prior to admission. Patients hospitalized in fiscal year 2008 and prescribed ChEI were identified. We reviewed electronic medical records. Of 282 patients, 15.6% (44) were new-starts and 84.4% (238) were continuations. Median length of stay was 16 days in new-starts versus 6 days in continuations (P < .05). Of new-starts, 38.6% were also treated of infection. Chart review additionally suggested possible treatment of delirium by initiation of benzodiazepines and antipsychotics in 11.4% and 22.7% of new-starts, respectively. We observed a substantive practice of initiating ChEIs in hospitalized elderly patients at risk of delirium. Although there was no difference in the 30-day mortality or readmission rates, new-starts were more likely to have a longer hospital stay than continuation patients.
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Affiliation(s)
- Kamal C Wagle
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.
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16
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Asghar-Ali AA, Wagle KC, Braun UK. Depression in terminally ill patients: dilemmas in diagnosis and treatment. J Pain Symptom Manage 2013; 45:926-33. [PMID: 23571209 DOI: 10.1016/j.jpainsymman.2012.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/27/2012] [Accepted: 12/01/2012] [Indexed: 12/25/2022]
Affiliation(s)
- Ali Abbas Asghar-Ali
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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17
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Harris PF, Arnold RM, Braun UK, Fromme E, Ghermay R, Harman S, Jayes RL, Walling AM. Update in palliative care--2011. J Gen Intern Med 2012; 27:582-7. [PMID: 22127796 PMCID: PMC3326102 DOI: 10.1007/s11606-011-1929-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/03/2011] [Accepted: 10/26/2011] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The aim of this update is to summarize scientifically rigorous articles published in 2010 that serve to advance the field of palliative medicine and have an impact on clinical practice. METHOD We conducted two separate literature searches for articles published between January 1, 2010 and December 31, 2010. We reviewed title pages from the Annals of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, JAMA, Journal of Clinical Oncology, JGIM, Journal of Pain and Symptom Management, Journal of Palliative Medicine, Lancet, New England Journal of Medicine, PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care). We also conducted a Medline search with the key words "palliative," "hospice," and "terminal" care. Each author presented approximately 20 abstracts to the group. All authors reviewed these abstracts, and when needed, full text publications. We focused on articles relevant to general internists. We rated the articles individually, eliminating by consensus those that were not deemed of highest priority, and discussed the final choices as a group. RESULTS We first identified 126 articles with potential relevance. We presented 20 at the annual SGIM update session, and discuss 11 in this paper.
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Affiliation(s)
- Patricia F Harris
- Keck School of Medicine, University of Southern California, 2020 Zonal Avenue, IRD 310, Los Angeles, CA 90089, USA.
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18
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Dy SM, Harman SM, Braun UK, Howie LJ, Harris PF, Jayes RL. To stent or not to stent: an evidence-based approach to palliative procedures at the end of life. J Pain Symptom Manage 2012; 43:795-801. [PMID: 22464354 PMCID: PMC4696003 DOI: 10.1016/j.jpainsymman.2011.12.269] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 12/16/2011] [Accepted: 12/31/2011] [Indexed: 11/26/2022]
Abstract
Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence to inform the decision, focusing on the specific question of whether the benefits of palliative biliary stents in patients with advanced cancer outweigh the risks. We then apply the evidence to the issue of how the primary and/or palliative care team and the interventionist communicate with patients and their families about the risks and benefits of palliative procedures. Review of the evidence found several prospective case series without control groups that measured patient-centered outcomes. Studies had high attrition rates, results for improvements in symptoms and quality of life were mixed, and rates of complications and short-term mortality were high. In conclusion, the limited evidence does not support that the benefits of palliative biliary stents in this population outweigh the risks. We propose that primary care teams consider and discuss the larger picture of the goals of care with patients and families when considering offering these procedures, as well as benefits and potential harms, and consider involving palliative care services early, before consultation with an interventionist.
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Affiliation(s)
- Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA.
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19
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Abstract
Many physicians will at some point care for patients who will receive life-sustaining treatment by default, because there are no instructions available from the patient as to what kind of care is preferred, and because surrogates are likely to ask for everything to be done when they do not know a patient's preferences. We use the methods of ethics informed by qualitative focus group research to identify 5 pathways to life-sustaining treatment by default originating with the patient's preferred decision-making style: deciding for oneself or letting others decide. We emphasize preventing the ethically unwelcome outcome of life-sustaining treatment by default by increasing the frequency with which patients make clear decisions or clearly express their values and goals that they then communicate to physicians or surrogates.
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Affiliation(s)
- Ursula K Braun
- Health Services Research and Development Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
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20
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Braun UK, Ford ME, Beyth RJ, McCullough LB. The physician's professional role in end-of-life decision-making: voices of racially and ethnically diverse physicians. Patient Educ Couns 2010; 80:3-9. [PMID: 19948388 PMCID: PMC2891864 DOI: 10.1016/j.pec.2009.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 10/21/2009] [Accepted: 10/26/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Previous studies have shown racial/ethnic differences in preferences for end-of-life (EOL) care. We aimed to describe values and beliefs guiding physicians' EOL decision-making and explore the relationship between physicians' race/ethnicity and their decision-making. METHODS Seven focus groups (3 Caucasian, 2 African American, 2 Hispanic) with internists and subspecialists (n=26) were conducted. Investigators independently analyzed transcripts, assigned codes, compared findings, reconciled differences, and developed themes. RESULTS Four themes appeared to transcend physicians' race/ethnicity: (1) strong support for the physician's role; (2) responding to "unreasonable" requests; (3) organizational factors; and (4) physician training and comfort with discussing EOL care. Five themes physicians seemed to manage differently based on race/ethnicity: (1) preventing and reducing the burden of surrogate decision-making; (2) responding to requests for "doing everything;" (3) influence of physician-patient racial/ethnic concordance/discordance; (4) cultural differences concerning truth-telling; and (5) spirituality and religious beliefs. CONCLUSIONS Physicians in our multi-racial/ethnic sample emphasized their commitment to their professional role in EOL decision-making. Implicitly invoking the professional virtue of self-effacement, they were able to identify racially/ethnically common and diverse ethical challenges of EOL decision-making. PRACTICE IMPLICATIONS Physicians should use professional virtues to tailor the EOL decision-making process in response to patients' race/ethnicity, based on patients' preferences.
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Affiliation(s)
- Ursula K Braun
- Houston VA Health Services Research & Development Center of Excellence, The Houston Center for Quality of Care & Utilization Studies, Department of Veteran Affairs, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
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21
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Lin AP, Orengo-Nania S, Braun UK. The PCP's role in chronic open-angle glaucoma. Geriatrics (Basel) 2009; 64:20-28. [PMID: 19586087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Chronic open-angle glaucoma is a leading cause of blindness and visual impairment in older adults. Optic nerve damage and the associated peripheral and subsequent central vision loss are irreversible, but early diagnosis and treatment will give patients the best chance to maintain functional vision and quality of life. Primary care physicians can assist with the diagnosis of glaucoma by making appropriate referrals for routine ophthalmic examinations, especially in patients with risk factors for glaucoma. Medication adherence and persistence may also be enhanced by discussing strategies to improve medication use and efficacy in the primary care setting. Recognition of adverse reactions from glaucoma medications and surgeries will allow proper management of these potentially serious conditions. Patients with advanced visual deficits can still benefit from treatment as well as low-vision and supportive care and should be referred for an ophthalmic evaluation. With an understanding of comprehensive glaucoma management, primary care physicians play an invaluable role in assisting their patients with effective and timely therapy that will result in improved outcomes.
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Affiliation(s)
- Albert P Lin
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
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22
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Braun UK, Naik AD, McCullough LB. Reconceptualizing the experience of surrogate decision making: reports vs genuine decisions. Ann Fam Med 2009; 7:249-53. [PMID: 19433843 PMCID: PMC2682974 DOI: 10.1370/afm.963] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 08/26/2008] [Accepted: 09/22/2008] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We propose a reconceptualization of surrogate decision making when patients lack an advance directive stating their preferences about life-sustaining treatment. This reconceptualization replaces the current 2-standard model of substituted judgment (based on the patient's prior preferences and values) and best interests (an assessment of how best to protect and promote the patient's health-related and other interests). METHODS We undertook a conceptual analysis based on the ethics of informed consent, a qualitative study of how surrogates of seriously ill patients experience the surrogate's role, and descriptions of decision making. RESULTS When the surrogate can meet the substituted judgment standard, the experience of the surrogate should be understood as providing a report, not making a decision. Surrogate decisions based on the best interest standard are experienced as genuine decisions, and the label "surrogate decision making" should be reserved to characterize only these experiences. CONCLUSIONS Physicians should identify clinically reasonable options and elicit the surrogate's sense of decision-making burden. Some surrogates will be able to make reports, and the physician should make a clear recommendation that implements the patient's reported preference. Some surrogates will confront genuine decisions, which should be managed by negotiating treatment goals. Requests by the surrogate that everything be done may represent a psychosocially burdensome decision, and support should be provided to help the surrogate work through the decision-making process.
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Affiliation(s)
- Ursula K Braun
- Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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23
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Poon I, Lal LS, Ford ME, Braun UK. Racial/Ethnic Disparities in Medication Use Among Veterans with Hypertension and Dementia: A National Cohort Study. Ann Pharmacother 2009; 43:185-93. [DOI: 10.1345/aph.1l368] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Hypertension and comorbid dementia are common illnesses affecting older adults disproportionally. Medication adherence is vital in achieving therapeutic outcomes. Use of antihypertensive and dementia medications may vary by race/ethnicity and has not been well explored. Objective: To evaluate the utilization of antihypertensive and dementia drugs and adherence in a national cohort of veterans aged 65 years or older with a diagnosis of both hypertension and dementia across different racial/ethnic groups. Methods: This was a retrospective cohort study that used 2 national databases of the Veterans Health Administration to estimate medication utilization and adherence rates among whites, African Americans, and Hispanics from 2000 to 2005. A medication possession ratio of 0.8 or greater defined adherence. The association between race/ethnicity and adherence was analyzed using multivariate logistic regression analysis. Results: A total of 56,561 patients (70.5% white, 15.6% African American, 6.6% Hispanic) aged 65 years or older had diagnoses of dementia and hypertension. African Americans were less likely than whites to receive angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers, acetylcholinesterase inhibitors, and memantine (p < 0.05). Hispanics were more likely than whites to be prescribed an ACE inhibitor and less likely to be prescribed an ARB, β-blocker, nondihydropyridine calcium-channel blocker (CCB), loop diuretic, β-agonist, or potassium-sparing diuretic (PSD) (p < 0.05). Medication adherence was significantly lower in African Americans than whites in all classes except for ARBs, loop diuretics, and PSDs (p < 0.05). Being Hispanic was associated with significantly lower adherence rates than whites for dihydropyridine CCBs and acetylcholinesterase inhibitors (p <0.05). Conclusions: Racial/ethnic differences exist in antihypertensive and dementia medication use in a cohort of older adults with hypertension and dementia. Adherence rates for a number of antihypertensive and dementia drugs are lower for minorities compared with whites. Healthcare providers should make special efforts to improve medication adherence among minorities.
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Affiliation(s)
- Ivy Poon
- Pharmacy Practice Department, Texas Southern University, Houston, TX; Adjunct Assistant Professor of Medicine, Baylor College of Medicine, Houston; Clinical Pharmacy Specialist, Department of Pharmacy, Michael E DeBakey VA Medical Center, Houston
| | - Lincy S Lal
- Pharmacoeconomic Research Specialist, Drug Use Policy and Pharmacoeconomics, Houston
| | - Marvella E Ford
- Department of Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina, Charleston, SC; Associate Director, Hollings Cancer Center, Cancer Disparity Program, Charleston
| | - Ursula K Braun
- Research Scientist and Staff Physician, Houston Center for Quality of Care & Utilization Studies, Sections of Geriatrics and Health Services Research, Michael E DeBakey VA Medical Center; Assistant Professor of Medicine and Medical Ethics, Baylor College of Medicine
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24
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Abbas Asghar-Ali A, Braun UK. Depression in geriatric patients. Minerva Med 2009; 100:105-113. [PMID: 19277008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
While the most serious of depressive illnesses in the elderly is major depressive disorder, patients' quality of life can be significantly impacted by dysthmic disorder, sub-threshold depression (minor depression), or a depressive disorder due to a general medical condition, all of which have been shown to be more prevalent than major depression in the community dwelling population of older adults. Older adults are also more likely to develop grief reaction and frequently deal with issues of bereavement. This review will discuss the diagnoses of all relevant depressive diagnoses that primary care physicians are likely to encounter. Among the many different assessment tools that screen for depression the briefest instruments are a two-question screening tool recommended by the U.S. Preventive Services Task Force and, specifically developed for older adults, the Geriatric Depression Scale (GDS) that is available in a short 15- Yes/No-question version. Many medical illnesses are associated with depressive symptoms. The focus in this review is on dementing illnesses/cerebrovascular disease, dementia of the Alzheimer's type, and Parkinson disease. First-line pharmacological therapy of depression includes selective serotonin inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Side effects of particular drugs can often be geared towards achieving additional benefits, e.g. weight gain associated with the use of some SSRISs may be helpful for patients with dementia.
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Affiliation(s)
- A Abbas Asghar-Ali
- Department of Psychiatry, Michael E. DeBakey VA Medical Center, Houston, TX, USA
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25
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Braun UK, Kunik ME, Pham C. Treating depression in terminally ill patients can optimize their physical comfort at the end of life and provide them the opportunity to confront and prepare for death. Geriatrics (Basel) 2008; 63:25-27. [PMID: 18512998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
The dying process is characterized by feelings of sadness and fear. It is normal for patients at the end of life to worry and grieve the loss of their health. However, when these feelings become excessive and interfere with all aspects of the patient's life, they are abnormal responses to the stress of terminal illness. Screening for depression in terminally ill patients can optimize their physical comfort at the end of life and provide them the opportunity to confront and prepare for death.
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Affiliation(s)
- Ursula K Braun
- Baylor College of Medicine, Houston Center for Quality of Care & Utilization Studies, Section of Geriatrics, Houston, Texas, USA
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26
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Affiliation(s)
- Ursula K Braun
- Houston Center for Quality of Care and Utilization Studies, Sections of Geriatrics and Health Services Research, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA.
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Abstract
BACKGROUND Older adults frequently have conditions requiring oral anticoagulation. Although clearly benefiting from oral anticoagulation, they are at increased risk for bleeding complications. Regular monitoring to optimize anticoagulation and to reduce the chance of major bleeding complications is required. The impact of oral anticoagulation monitoring by pharmacists in patients older than 75 years of age has not been described well. OBJECTIVE To compare warfarin therapy prescribed and monitored by physicians to a pharmacist-monitored anticoagulation service in a cohort of older veterans. METHODS Retrospective chart review utilizing the Houston VA Medical Center's pharmacy database. Among all outpatients aged 75 years or older filling warfarin prescriptions between 1 March 2003 to 1 March 2005, and who were either monitored in a pharmacist's clinic or not, 103 patients per group were randomly selected. Information on demographics, indication for and length of warfarin therapy, INR values, and thromboembolic and bleeding events were abstracted. Differences were analysed using chi-squared test, Fisher's Exact test, and unpaired Student t-test. RESULTS A total of 1521 patients (440 in the pharmacist-monitored group, 1081 in the traditionally monitored group) met our inclusion criteria. One hundred and three patients per group were randomly selected for chart review. Although no significant difference in percentage of therapeutic INR values (48.1% pharmacist group, 46.4% conventional group) or in the incidence of major bleeding events was found, thromboembolic events occurred significantly less frequently in the pharmacist-monitored group (2 events vs. 12 events, P = 0.01). Minor bleeding events were more frequent in the pharmacist-monitored group (50 vs. 17, P < 0.01). However, time to follow-up after a sub- or supra-therapeutic INR was significantly shorter in the pharmacist monitored group (22 days vs. 68 days, and 14 days vs. 32 days, respectively). CONCLUSION Pharmacist-monitored anticoagulation was associated with reduced thromboembolic events, an increase in minor bleeding events, and no difference in major bleeding events. Overall such monitoring by pharmacists should be recommended for older adults.
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Affiliation(s)
- I O Poon
- Pharmacy Department, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA.
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Braun UK, Rabeneck L, McCullough LB, Urbauer DL, Wray NP, Lairson DR, Beyth RJ. Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding for Veterans with DementiaâRacial Differences Remain. J Am Geriatr Soc 2005; 53:242-8. [DOI: 10.1111/j.1532-5415.2005.53109.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Braun UK, Kunik ME. Behavioral disturbances in dementia: finding the cause(s). Geriatrics (Basel) 2004; 59:32, 34. [PMID: 15667020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Affiliation(s)
- Ursula K Braun
- Baylor College of Medicine, Sections of Geriatrics and Health Services Research, Houston Center for Quality of Care & Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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