Clinical Guidelines for Voluntarily Stopping Eating and Drinking (VSED)

As the care of patients with serious illness increasingly emphasizes clarifying goals of care, exploring quality of life, and minimizing patients' symptom burden, voluntarily stopping eating and drinking (VSED) has emerged as a topic of increasing interest for patients who face a diminishing quality of life. It is an option for those with serious illness that is legal in every state in the country, but for which there are few published comprehensive guidelines-and none specific to the American medical system-even as public awareness and the number of inquiries regarding this action increase. In addition to the ethical questions raised by the practice and support of VSED, there are also clinical, logistical, institutional, social, religious, spiritual, and administrative considerations for clinicians who are asked to respond to patients' inquiries about VSED and who discuss this option in end-of-life care. With these clinical guidelines, we seek to provide practical recommendations for clinicians who consider providing support to their patients who contemplate and/or undertake this effort to hasten death.

Application of a person-centered prescription model improves pharmacotherapeutic indicators and reduces costs associated with pharmacological treatment in hospitalized older patients at the end of life

Objective

This study sought to investigate whether applying an adapted person-centered prescription (PCP) model reduces the total regular medications in older people admitted in a subacute hospital at the end of life (EOL), improving pharmacotherapeutic indicators and reducing the expense associated with pharmacological treatment.

Design

Randomized controlled trial. The trial was registered with ClinicalTrials.gov (NCT05454644).

Setting

A subacute hospital in Basque Country, Spain.

Subjects

Adults ≥65 years (n = 114) who were admitted to a geriatric convalescence unit and required palliative care.

Intervention

The adapted PCP model consisted of a systematic four-step process conducted by geriatricians and clinical pharmacists. Relative to the original model, this adapted model entails a protocol for the tools and assessments to be conducted on people identified as being at the EOL.

Measurements

After applying the adapted PCP model, the mean change in the number of regular drugs, STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with limited life expectancy) criteria, drug burden index (DBI), drug-drug interactions, medication regimen complexity index (MRCI) and 28-days medication cost of chronic prescriptions between admission and discharge was analyzed. All patients were followed for 3 months after hospital discharge to measure the intervention's effectiveness over time on pharmacotherapeutic variables and the cost of chronic medical prescriptions.

Results

The number of regular prescribed medications at baseline was 9.0 ± 3.2 in the intervention group and 8.2 ± 3.5 in the control group. The mean change in the number of regular prescriptions at discharge was -1.74 in the intervention group and -0.07 in the control group (mean difference = 1.67 ± 0.57; p = 0.007). Applying a PCP model reduced all measured criteria compared with pre-admission (p < 0.05). At discharge, the mean change in 28-days medication cost was significantly lower in the intervention group compared with the control group (-34.91€ vs. -0.36€; p < 0.004).

Conclusion

Applying a PCP model improves pharmacotherapeutic indicators and reduces the costs associated with pharmacological treatment in hospitalized geriatric patients at the EOL, continuing for 3 months after hospital discharge. Future studies must investigate continuity in the transition between hospital care and primary care so that these new care models are offered transversally and not in isolation.

End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study

BACKGROUND AND AIM

End-of-Life (EOL) decision-making in paediatric critical care can be complex and heterogeneous, reflecting national culture and law as well as the relative resources provided for healthcare. This study aimed to identify similarities and differences in the experiences and attitudes of European paediatric intensive care doctors, nurses and allied health professionals about end-of-life decision-making and care.

METHODS

This was a cross-sectional observational study in which we distributed an electronic survey to the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members by email and social media. The survey had three sections: (i) 16 items about attitudes to EOL care, (ii) 14 items about EOL decisions, and (iii) 18 items about EOL care in practice. We used a 5-point Likert scale and performed descriptive statistical analysis.

RESULTS

Overall, 198 questionnaires were completed by physicians (62%), nurses (34%) and allied health professionals (4%). Nurses reported less active involvement in decision-making processes than doctors (64% vs. 95%; p < 0.001). As viewed by the child and family, the child's expected future quality of life was recognised as one of the most critical considerations in EOL decision-making. Sub-analysis of Northern, Central and Southern European regions revealed differences in the optimal timing of EOL decisions. Most respondents (n = 179; 90%) supported discussing organ donation with parents during EOL planning. In the sub-region analysis, differences were observed in the provision of deep sedation and nutritional support during EOL care.

CONCLUSIONS

This study has shown similar attitudes and experiences of EOL care among paediatric critical care professionals within European regions, but differences persist between European regions. Nurses are less involved in EOL decision-making than physicians. Further research should identify the key cultural, religious, legal and resource differences underlying these discrepancies. We recommend multi-professional ethics education to improve EOL care in European Paediatric Intensive Care.

Chemotherapy and targeted therapy near the end of life affects aggressiveness of palliative care

BACKGROUND

The purpose of this study was to explore the difference in quality indicators for chemotherapy or targeted therapy for patients with cancer in their last month of life.

METHODS

A total of 585 patients who had received targeted therapy or palliative chemotherapy (PCT) from April 2007 to December 2018 at the Department of Integrated Therapy of Fudan University Shanghai Cancer Center were included in this retrospective study. The patients' social demographic and clinical data were collected, and variables judged to be independent predictors of PCT or targeted therapy were selected for univariate and multivariate analyses of differences.

RESULTS

Treatment with PCT was independently associated with age (P<0.001) and performance status (PS) (P<0.001). Treatment with targeted therapy was independently associated with PS (P<0.001). Patients who received continued chemotherapy or cardiopulmonary resuscitation (CPR) within the last month of life were subjected to more intensive treatment in comparison with those who did not know when they were admitted to the intensive care unit (ICU) in the last month of life (P<0.001). Subgroup analysis showed that lung cancer was independently associated with targeted therapy (P<0.001), and admission to the ICU was independently associated with PCT (P<0.001).

CONCLUSIONS

In the last month of life, approximately 14.9% of patients with cancer received PCT, which conformed to international recommendations. Lower CPR rates and admission to the ICU were positively correlated with targeted therapy versus those who received chemotherapy at the end of life (EOL).

Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU)

This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.

Overcoming the challenges associated with symptom management in palliative care

End of life (EOL) care is a topic that many families have difficulty discussing. A number of families are uncomfortable with accepting the fact that death is a part of every human's reality. Ideas and thoughts of death are interpreted differently across various cultures, and lacking to discuss disease trajectory and what to expect down the road with a physician, brings forward conflict during EOL care. Let us consider the complexities of treating Mr. X who is an 80-year-old male of Italian background with a history of advanced lung cancer with metastasis to the brain. He was recently diagnosed and his health began to rapidly decline at home. Mr. X is used in this case study to explore the challenges in providing care in a palliative care unit (PCU), and the ways in which we can overcome them.