PC-FACS

Abstract

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6-10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6-10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27(17):2758-2765. Loggers ET, Maciejewski PK, Paulk E, et al. Racial differences in predictors of intensive end-of-life care in advanced cancer patients. J Clin Oncol 2009;27(33):5559-5564. Hinds PS, Oakes LL, Hicks J, et al. “Trying to be a good parent” as defined by interviews with parents who made phase I, terminal care, and resuscitation decisions for their children. J Clin Oncol 2009 Oct 5 [Epub ahead of print]. Kurella Tamura M, Covinsky KE, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361(16):1539-1547. Thorne FM, Morley S. Prospective judgments of acceptable outcomes for pain, interference and activity: patient-determined outcome criteria. Pain 2009;144(3):262-269. Fitchett G, Rasinski K, Cadge W, Curlin FA. Physicians' experience and satisfaction with chaplains: a national survey. Arch Intern Med 2009;169(19):1808-1809. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. New Engl J Med 2009;361(16):1529-1538. Vidán MT, Sánchez E, Alonso M, et al. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 2009 Sep 15 [Epub ahead of print]. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc 2009;57(7):1191-1196. Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc 2009;57(8):1395-1402. A sense of having been a good parent to a dying child helps parents emotionally survive the experience and loss. How do parents of children with terminal cancer define “being a good parent?” In this qualitative study, eligible parents had made one of three treatment decisions during the previous 72 hours: (a) whether to enroll in a Phase I study, (b) to initiate a DNR order, or (c) to initiate terminal care (i.e., discontinue disease-directed therapy while continuing aggressive symptom management). Open-ended questions asked parents (1) their definition of being a good parent at this time, and (2) how staff could help them fulfill this role. Trained raters independently coded responses. Participants (n=62) were mean age 38 (SD 8), 91% mothers, 45% white. Regarding definition of “a good parent,” the most frequent theme (89% of interviews) was “doing right by my child,” followed by “being there for my child” (48%) and “conveying love to my child” (42%). Regarding staff actions, the most frequent theme was “all that can be done is being done.” Positive clinician behaviors consistently experienced were “staff respect me and my decisions,” “staff know our special needs,” “staff like our child,” “staff tell us we are good parents,” and “staff give us time to decide.” Clinician behaviors that parents desired to see increased or initiated were “continue to comfort my child and me,” “be pleasant,” “coordinate care,” “ask about our faith,” “give us the facts,” “don't quit on us,” “don't forget us,” “keep including my child,” and “provide more material items and support options.” Prior work by Hinds and colleagues identified that, among children with terminal cancer, parents often describe themselves as trying to be a good parent in making decisions on behalf of their child. The current study builds on this finding by further elucidating, from the perspective of parents, what it means to be a good parent and how staff can support this fundamental value. Prevalent themes were identified as noted in the results, and the authors propose a qualitatively derived definition of being a good parent to a child with incurable cancer. Most importantly, however, the study validates the need to inquire about parents' values regarding their children and how staff can work to honor these values. Most parents of children with incurable cancer hold values about what it means to them to be “a good parent.” In order for staff to best serve the needs of children with incurable cancer and their families, staff should inquire about such values and act to honor these individualized goals. Joanne Wolfe, MD, MPH, Children's Hospital Boston and Dana-Farber Cancer Institute, Boston, MA. Hinds PS, Oakes LL, Hicks J, et al. “Trying to be a good parent” as defined by interviews with parents who made phase I, terminal care, and resuscitation decisions for their children. J Clin Oncol 2009 Oct 5 [Epub ahead of print]. Increasing numbers of elderly patients with end-stage renal disease are starting dialysis1 despite high mortality rates in the first year after dialysis initiation.2 Is functional status maintained after initiating dialysis? This retrospective database study linked data from the U.S. Renal Data System, which captures>99% of Americans starting dialysis, with data from the Minimum Data Set, a registry of U.S. nursing home residents. The study included nursing home residents who started treatment with dialysis from 1998-2000 and had at least one functional status measurement before dialysis initiation. Functional status was measured using the Minimum Data Set-Activities of Daily Living ([MDS-ADL]; 0-28 scale, higher scores indicating poorer function). Participants (n=3,702) were mean age 73 (SD 11); 60% female; 64% white, 32% black; 68% diabetes, 66% congestive heart failure, and 44% coronary artery disease. Functional status declined from three months before initiation of dialysis (median MDS-ADL, 12) to three months after dialysis initiation (median, 16). At three months after dialysis initiation, 39% of participants had maintained predialysis functional status; by 12 months, 58% had died and only 13% had maintained functional status. In a random-effects model, initiation of dialysis was associated with a sharp decline in functional status (increase of 2.8 points in MDS-ADL score; 95% CI, 2.5-3.0); this decline was independent of age, sex, race, and functional-status trajectory before dialysis. After adjusting for accelerated functional decline during the three months before dialysis, the functional status decline associated with initiating dialysis remained significant (1.7 points; 95% CI, 1.4-2.1). This is an important initial study of functional outcomes pre- and postdialysis in an elderly nursing home population. The goal of dialysis (a palliative intervention) in this group is to increase quality of life independent of renal function and with tolerable burden of treatment. Predialysis decline, the indicator for dialysis, may also indicate functional decline that cannot be reversed by down-regulation of serum creatinine. Paradoxically, dialysis may hasten this decline. The data teased out a predictable group who were unlikely to maintain function postdialysis, identified by age, race, sex, comorbidities, low albumin, and hospitalization. One in eight patients actually maintained function postdialysis. These groups require further study and a dialysis/no dialysis trial involving palliative interventions. Palliative care has much to offer patients symptomatic from end-stage renal failure and may increase quality of life compared with dialysis as implicated by this study. Alan Nixon, MB BCh, BAO, FAAHPM, Richmond Hospital, Richmond, British Columbia, Canada. Kurella Tamura M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009;361(16):1539-1547. 1.Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-183.2.Collins AJ, Kasiske B, Herzog C, et al. Excerpts from the United States Renal Data System 2004 annual data report: atlas of end-stage renal disease in the United States. Am J Kidney Dis 2005;45(1 Suppl 1):A5-7, S1-280. Physicians play a critical role in directing chaplains toward appropriate patients. Do physicians' practice contexts and views about religion/spirituality (R/S) influence their experiences and satisfaction with chaplains? This was a national survey of U.S. physicians<65 years old from any specialty. Analyses examined physicians' reports of prior experience with chaplains (yes/no) and satisfaction with chaplains (satisfied/dissatisfied). Predictor variables included demographics, training about R/S in medicine, practice setting, personal R/S, opinions about addressing R/S in clinical care, and frequency of observing R/S effects. Participants (n=1,102) were 74% male; 31% at teaching hospitals, 12% at faith-based hospitals/clinics; and 64% cared for high numbers of critically ill patients. Fifty-nine percent reported being Christian, 16% Jewish, and 14% reported other affiliations. Response rate was 63%. Eighty-nine percent of physicians reported experience with chaplains; 90% of these physicians were satisfied or very satisfied. In multivariate logistic regression, experience with chaplains was associated with training about R/S in medicine (OR, 3.7), high load of critically ill patients (OR, 1.8), practicing psychiatry or obstetrics/gynecology (both OR, 3.4), experience of positive effects of R/S on patients (OR, 2.3), and believing it is appropriate to talk with patients about R/S when the physician deems appropriate (OR, 2.7). Higher satisfaction was associated with practicing medical subspecialties (OR, 3.4), working in teaching hospitals (OR, 1.9), experiencing positive effects of R/S on patients (OR, 2.7), and believing it is appropriate to pray with patients whenever the physician deems appropriate (OR, 3.5). Physicians from the Northeast were less likely to be satisfied with chaplains. This survey looks at the important issue of how physicians experience chaplain involvement with their patients. While an initial reaction might be to question why this matters since the more critical issue is patient and family experience, physicians are currently one underutilized gateway by which patients are referred to chaplaincy services. Of note, 41% of respondents agreed with the statement “My whole approach to life is based on my religion,” and another 41% believed it was appropriate for them to talk about their own religion and spiritual beliefs with patients when the patient asked about it. The fact that physicians in the Northeast were less likely to be satisfied with chaplains is also of interest. Unfortunately, this brief article does not include the number of physicians from the Northeast or a breakdown of their religious affiliation. Whether there is a relationship between religious affiliation and satisfaction with chaplains remains an open question. Importantly, as well, one has to recognize that physicians have little knowledge of how chaplains interact with patients and families and little training themselves in what role a chaplain can play. A consensus group recently published guidelines looking at establishing end-of-life competencies and guidelines for chaplains.1 Given growing awareness regarding the importance of religion and spirituality in the lives of Americans, surveys such as this are an important part of a rich body of research that can only help improve end-of-life care. Gail Gazelle, MD, FACP, FAAHPM, Harvard Medical School, Boston, MA. Fitchett G, Rasinski K, Cadge W, Curlin FA. Physicians' experience and satisfaction with chaplains: a national survey. Arch Intern Med 2009;169(19):1808-1809. 1.Puchalski C, Ferrell B, Virani R, et al. Improving the quality of spiritual care as a dimension of palliative care: the report of the consensus conference. J Pall Med 2009;12(10):885-904. Patients with advanced dementia have a high but underrecognized mortality risk and may receive suboptimal palliative care.1-3 What symptoms and complications characterize these patients at or near the end of life? This was a prospective cohort study of nursing home (NH) residents with advanced dementia and their health care proxies, recruited from 22 large NHs (> 60 beds). Eligibility criteria included length of NH stay>30 days; dementia-related cognitive impairment; stage 7 on the Global Deterioration Scale (1-7 scale); and availability of health care proxy. Data were collected from chart review, interviews with nurses, and physical examination at baseline and every three months for 18 months. Participants (n=323) were mean age 85 years (SD 8); 85% female; 90% white; median length of NH stay three years; and 72% with Alzheimer's, 17% vascular, and 11% other type of dementia. Fifty-five percent of participants died over the 18 months. Probability of pneumonia was 41%; of a febrile episode, 53%; and of an eating problem, 86%. Adjusted six-month mortality rates after development of pneumonia, febrile episode, and eating problems were 47%, 45%, and 39%, respectively; these rates were substantially higher than those for NH residents without such complications. Proportions of participants experiencing symptoms were dyspnea (≥ 5 days/month), 46%; pain (≥ 5 days/month), 39%; pressure ulcers (≥ stage II), 39%; agitation, 54%; and aspiration, 41%. Of 323 participants, 22% were referred to hospice during the 18-month period; of 177 who died, 30% received hospice referrals. Only 18% of health care proxies stated that a physician had given them prognostic information; 33% stated that a physician had counseled them about complications associated with advanced dementia. Patients in NH with advanced dementia need palliative care. The disease is terminal (25% of patients with advanced dementia die in six months and half in 18 months) and carries significant suffering that is potentially treatable (pain, dyspnea, agitation). While prognostic uncertainty is often a barrier to hospice use, higher mortality rates at six months after pneumonia, febrile episode, or eating problems may support hospice admission. This study provides quantitative information to give anticipatory guidance to patients and families with dementia. Few proxies received anticipatory guidance, but the impact may be profound. Burdensome interventions occurred despite the fact that 96% of proxies stated comfort was the main goal. When proxies understood both prognosis and expected clinical complications, the patient was much less likely (adjusted OR, 0.12; 95% CI, 0.04-0.37) to receive burdensome interventions. Advanced dementia is associated with significant symptom burden and is terminal, with higher six-month mortality rates after pneumonia, febrile illness, or eating problems. Patients whose health care proxies understand the prognosis and course are less likely to receive burdensome care. Paul Tatum, MD, University of Missouri, Columbia, MO. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. New Engl J Med 2009;361(16):1529-1538. 1.Sachs GA, Shega JW, Cox-Hayley D. Barriers to excellent end-of-life care for patients with dementia. J Gen Intern Med 2004;19:1057-1063.2.Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing home. Arch Intern Med 2004; 164:321-326.3.Di Giulio P, Toscani F, Villani D, et al. Dying with advanced dementia in long-term care geriatric institutions: a retrospective study. J Palliat Med 2008;11:1023-1028. Delirium is associated with higher rates of mortality and morbidity,1 functional decline,2 and institutionalization.3,4 Can a nonpharmacological intervention implemented in daily practice prevent delirium in older, hospitalized, at-risk patients? This was a one-year, prospective, nonrandomized, controlled clinical trial of a multicomponent delirium-prevention intervention vs. usual care (UC) for patients > 70 years old. Participants were consecutive patients in a hospital geriatric unit (intervention) and two internal medicine wards (control). The intervention, a quality improvement initiative, consisted of an educational program plus specific actions in seven areas (orientation, sensory impairment, sleep, mobilization, hydration, nutrition, drug use). Adherence was monitored daily. Eligible patients did not have delirium upon admission but had ≥1 of 4 risk factors: cognitive impairment, visual impairment, acute disease severity, dehydration. Primary endpoint was delirium incidence; secondary endpoint was functional decline. Participants (n=542) were mean age 83 years (SD 6); 56% female; and 34% high risk of delirium. Intervention patients were older and more cognitively impaired, with lower functional status and higher risk of delirium, than control patients. Delirium affected 12% of intervention and 19% of control patients (P=0.04); severity, length, and recurrence of delirium episodes were similar across groups. Adherence to the intervention protocol was 76%. After adjusting, the intervention was associated with lower delirium incidence (OR=0.4; 95% CI, 0.24-0.77; P=0.005), slower rate of functional decline (46% intervention vs. 56% control; P=0.03), and improved quality indicators (e.g., mobilization, fewer physical restraints). The intervention was more effective in intermediate-risk than high-risk patients. Delirium is a common problem among palliative care patients – one that is often seen as inevitable and untreatable. This study challenges that view and suggests that simple interventions may be effective in decreasing the incidence of delirium. Another important lesson is that efforts to prevent delirium may be more effective than treatment of delirium. Although this study was limited by the nonrandom allocation of patients to treatment and a single study site, the nondrug intervention is simple and relatively easy to implement by existing unit staff. Further research could test whether or not the intervention and positive outcomes can be replicated in other settings, including nursing homes and inpatient palliative care and hospice units. Family caregivers also can be taught to perform most of the components of the program. A simple quality improvement intervention can decrease the incidence of delirium. Mary Ersek, PhD, RN, FAAN, University of Pennsylvania School of Nursing, Philadelphia, PA. Vidán MT, Sánchez E, Alonso M, et al. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 2009 Sep 15 [Epub ahead of print]. 1.McCusker J, Cole MG, Abrahamowicz M, et al. Delirium predicts 12-month mortality. Arch Intern Med 2002;162:457-463.2.Murray AM, Levkoff SE, Wetle TT, et al. Acute delirium and functional decline in the hospitalized elderly patient. J Gerontol 1993;48:M181-186.3.Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. Can Med Assoc J 1993;149:41-46.4.Inouye SK, Rushing JT, Foreman MD, et al. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998;13:234-242. Amy P. Abernethy, MD, FAAHPM, of Duke University Medical Center, is the Editor-in-Chief of PC-FACs. Donna S. Zhukovsky, MD, FACP, of UT M.D. Anderson Cancer Center, is Associate Editor-in-Chief. The editors thank Jane Wheeler, MSPH, and Robin Fowler for their assistance in compiling this feature. The AAHPM thanks the following for their reviews of the critical summaries and preparation of the commentaries: Robert M. Arnold, MD Stephen Bekanich, MD Janet Bull, MD Ira Robert Byock, MD Ronald J. Crossno, MD, CMD, FAAHPM Mellar P. Davis, MD, FCCP Mary Ersek, PhD, RN, FAAN Tommie W. Farrell, MD Betty Ferrell, PhD, RN, FAAN Perry G. Fine, MD Daniel Fischberg, MD, PhD Anthony Nicholas Galanos, MA, MD Gail Gazelle, MD, FACP, FAAHPM Harry Goforth, MD Laura Hanson, MD, MPH Peter Mahler, MD, PhD John F. Manfredonia, DO Gregory J. Miller, MD J. Cameron Muir, MD Alan Nixon, MB BCh, BAO, FAAHPM David Nowels, DM John Peppin, DO, FACP Francine Rainone, DO, PhD Brad Stuart, MD Paul E. Tatum III, MD James A. Tulsky, MD Joanne Wolfe, MD The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and/or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 4700 West Lake Avenue Glenview, IL 60025-1485, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org