Hospice Placement Research Articles

S2673 If It Bleeds, It Leads: Endoscopic Presentation of Hemosuccus Pancreaticus

Introduction: A 65 year old male presented as a transfer for further evaluation of multifactorial shock. Pertinent medical comorbidities included active alcohol use disorder and mild alcohol associated hepatitis. On OSH presentation, he was treated for multifactorial shock in setting of new atrial fibrillation with rapid ventricular response and MSSA bacteremia, and was subsequently transferred to our facility. Case Description/Methods: On arrival, he had been started on systemic anticoagulation in light of his new diagnosis of atrial fibrillation and had downtrending hemoglobin from previously normal baseline ∼15 to a nadir of 7-8. Several episodes of witnessed melena were documented, and the gastroenterology service was consulted. He had no known prior history of GI bleeding or cirrhosis. Endoscopic evaluation noted a small amount of hematin in the stomach without concerning source lesions. Examination of the duodenum was initially only notable for scant fresh red blood and small, clean based ulcers thought secondary to recent hypotension and ischemia. On prolonged examination of the duodenum intermittent fresh blood was observed originating from the ampulla, consistent with a diagnosis of hemosuccus pancreaticus. Follow up dedicated CT angiography showed a thrombosed aneurysm in the pancreatic head, abutting the distal main pancreatic duct, that was concerning for the likely source lesion. The patient and family were offered interventional radiology intervention, but instead opted for hospice placement. Discussion: Hemosuccus pancreaticus is typically associated with pancreatic pathology that ultimately causes luminal bleeding via erosion of pancreatic blood vessels in communication with the pancreatic duct. The source of bleeding is often an arterial aneurysm or pseudoaneurysm and associated bleeding can be severe and life-threatening. Active hemorrhage from the duodenal ampulla is a rare endoscopic finding and bleeding in cases of hemosuccus pancreaticus is frequently intermittent. In patients with obscure upper GI bleeding and the appropriate risk factors, a high index of suspicion is required to ultimately make the diagnosis. (Figure) Given the frequency of associated vascular abnormalities, all patients with suspected or confirmed hemosuccus pancreaticus merit dedicated vascular imaging and if a vascular lesion is identified, angiography and coil embolization are the preferred definitive management.Figure 1.: Intermittent active bleeding from ampulla consistent with endoscopic diagnosis of hemosuccus pancreaticus.

When Death Arrives.

When Death Arrives.

MALIGNANT PERIPHERAL NERVE SHEATH TUMOR SPREAD TO THE THORACIC CAVITY CAUSING OBSTRUCTIVE SHOCK

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Malignant peripheral nerve sheath tumor (MPNST) is a rare and aggressive subtype of sarcoma, which originates from peripheral nerves. MPNST can present sporadically or in association with neurofibromatosis type 1 (NF1). In this case we describe a patient with a rare spread of MPNST to her thoracic cavity resulting in a combination of obstructive and septic shock leading to death. CASE PRESENTATION: A 30 year old female with NF1 and MPNST presented with right flank pain of 5 days duration. The patient was found to have leukocytosis in the setting of hydronephrosis and was subsequently admitted. She quickly decompensated, becoming tachycardic and hypotensive. Computed tomography angiography of the abdomen and pelvis revealed severe hydronephrosis secondary to large abdominal mass effect and intrathoracic mass extending into the right middle lobe of the lung with invasion of the right and left atrium. Subsequently, she was transferred to the medical intensive care unit for mixed obstructive and septic shock requiring intubation and vasopressor support. Transthoracic echocardiogram revealed a small left ventricle cavity and an echogenic density 1.96 x 2.75 cm compressing the left atrium which appeared to be mass effect from the intrathoracic sarcoma. While awaiting hospice placement, she became bradycardic and was unable to be resuscitated, and ultimately succumbed to her condition. DISCUSSION: MPNST is defined as malignant tumors arising from peripheral nerves or as benign neurogenic tumors converted into malignant tumors. Although MPNST primarily affects extremities, it can rarely also occur in the thoracic cavity. The majority of MPNST occur on the right side of the heart, in close proximity to the interatrial septum, likely because of the origin of MPNST from cardiac branches of the vagus nerve and cardiac plexus. However, the presence of MPNST on the left side has also been reported. As with this patient, patients with Neurofibromatosis type I carry an increased risk for MPNST between 8-13%. In this case, the significant and severe spread of this patient’s MPNST caused multiple obstructions in the urinary system as well as within the heart, ultimately leading to the mixed shock. The most effective treatment for MPNST is complete excision, which unfortunately is not always possible in advanced stages. CONCLUSIONS: MPNST can be very difficult to treat due to its aggressive nature leading to terrible complications including obstruction and early death. In this case, the patient not only had MPNST, but also an even rarer spread to the thoracic cavity ultimately leading to her death. It is important to recognize that this disease process can escalate to a shock state and must be treated accordingly. Whenever possible, palliative care should be involved in patient care early to establish goals of care. Reference #1: Evans DG, Baser ME, McGaughran J, et al. Malignant peripheral nerve sheath tumours in neurofibromatosis 1. J Med Genet 2002; 39:311. Reference #2: Li S, Qiu Y, Yu J, Liang C, Peng L. Cardiac malignant peripheral nerve sheath tumor on computed tomography and magnetic resonance imaging: A case report. Medicine (Baltimore). 2019;98(44):e17463. doi:10.1097/MD.0000000000017463 Reference #3: Prifti E, Baboci A, Ikonomi M. A giant cardiac malignant peripheral nerve sheath tumor presenting with total obstruction of the superior vena cava. Ann Thorac Surg. 2014;97(1):e7-e9. doi:10.1016/j.athoracsur.2013.08.044 DISCLOSURES: No relevant relationships by Christopher Izzo, source=Web Response No relevant relationships by Nimeh Najjar, source=Web Response No relevant relationships by Spencer Streit, source=Web Response

Education and Training: Perceived educational impact, ­challenges and opportunities of hospice placements for foundation year doctors: a qualitative study

Foundation year one doctors (F1s) are expected to recognise and care for dying patients, but previous studies have found they can feel unprepared, stressed and unsupported when faced with such situations. Although hospice placements can provide good experiential learning for junior doctors, no studies to date have included F1s. This study used an interpretivist approach to explore educational opportunities and challenges in hospice placements from an F1's perspective. Six F1s who had recently completed hospice placements were interviewed individually. Data analysed qualitatively showed that F1s valued informal experiential learning and felt well supported by senior doctors. The most important learning outcome was the acquisition of enhanced communication skills and challenges included the risk of becoming medically deskilled. F1s felt their medical practice had changed as a result of hospice placement, most commonly in communication skills and recognition of the dying phase. The author recommends increased utilisation of hospice placements in foundation training programmes.

Identifying patients at risk of inhospital death or hospice transfer for early goals of care discussions in a US referral center: the HELPS model derived from retrospective data

ObjectiveCreate a score to identify patients at risk of death or hospice placement who may benefit from goals of care discussion earlier in the hospitalisation.DesignRetrospective cohort study to develop a...

End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home

ABSTRACTEducation about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N = 300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.

University-Community-Hospice Partnership to Address Organizational Barriers to Cultural Competence.

Research documents a lack of access to, utilization of, and satisfaction with hospice care for African Americans. Models for culturally competent hospice services have been developed but are not in general use. Major organizational barriers include (1) lack of funding/budgeting for additional staff for community outreach, (2) lack of applications from culturally diverse professionals, (3) lack of funding/budgeting for additional staff for development of culturally competent services, (4) lack of knowledge about diverse cultures, and (5) lack of awareness of which cultural groups are not being served. A participatory action research project addressed these organizational barriers through a multicultural social work student field placement in 1 rural hospice. The effectiveness of the student interventions was evaluated, including addressing organizational barriers, cultural competence training of staff, and community outreach. Results indicated that students can provide a valuable service in addressing organizational barriers through a hospice field placement.

Increased Body Mass Index Is Associated with Congestive Heart Failure and Mortality in Adult Fontan Patients.

Obesity affects adults with congenital heart disease (CHD). The effect of an increased body mass index (BMI) with respect to morbidity and mortality has not been evaluated in adults with complex CHD. Our objective was to evaluate the effects of increased BMI on heart failure and mortality in univentricular patients who had undergone Fontan palliation. A query of Fontan patients' first appointments at the Washington University Center for Adults with CHD between 2007 and 2014 yielded 79 patients. BMI status as normal (<25 kg/m(2) ), overweight (≥25, <30 kg/m(2) ), and obese (≥30 kg/m(2) ) was established at the patient's first appointment. We analyzed demographics, diuretic requirements, New York Heart Association (NYHA) class, and laboratory values using Student's two-sample t-test and Fisher's exact test. Mortality was assessed via survival curves, and hazard ratios were compiled with proportional hazard modeling. The recent average BMI was significantly greater in patients with NYHA classes II-IV (29.3 ± 9 kg/m(2) ) compared with asymptomatic patients (24.8 ± 5.1 kg/m(2) , P = .006). Additionally, the average BMI of patients with a high diuretic requirement (≥40 mg/day IV furosemide equivalent) was obese, at 32.15 ± 9.1 kg/m(2) , compared with 25.91 ± 7.3 kg/m(2) for those on no or lower doses of diuretics (P = .009). Eighteen of the 79 patients met an endpoint of death, hospice placement, or cardiac transplant by the study conclusion. Kaplan-Meier analysis from time of first appointment until recent follow-up revealed a significant association between time to combined endpoint and BMI class. Cox proportional hazard modeling with age adjustment yielded a hazard ratio of 3.2 (95% CI 1.096-9.379) for obesity upon first presentation to an adult CHD clinic. In patients with univentricular hearts and Fontan palliation, obesity is associated with symptomatic heart failure and mortality.

Palliation of malignant gastric outlet obstruction with simultaneous endoscopic insertion of afferent and efferent jejunal limb enteral stents in patients with recurrent malignancy.

Patients with prior pancreaticobiliary or distal gastric cancer treated surgically may have local anastomotic recurrence with obstruction of the afferent and efferent jejunal limbs. This report describes the efficacy and safety of simultaneous endoscopic insertion of self-expanding metal stents into the afferent and efferent jejunal limbs in patients with gastric outlet obstruction (GOO) of post-surgical anatomy for palliation of recurrent malignancy. Patients were identified from an endoscopic database at a specialized cancer center between September 2007 and March 2014. Technical success was defined as single-session insertion of afferent and efferent jejunal limb enteral stents. Clinical success was defined as immediate symptom relief and ability to advance diet. A durable response was defined as symptom relief of at least 60 days or until hospice placement or death. Twenty-three patients were identified who underwent insertion of two 22-mm-diameter uncovered duodenal stents. Stent length varied from 60 to 120 mm. Stents were placed under endoscopic and fluoroscopic guidance. Three patients required balloon dilation to facilitate stent insertion. Average procedure time was 58.8 min (range 28-120). Technical success was achieved in 23/24 (96%) patients. Clinical success was achieved in 19/23 (83%) patients. Following initial stent insertion and prior to subsequent re-intervention, 11/19 (58%) patients had a durable response with a median duration of 70 days (range 4-315). Eight (42%) patients underwent subsequent re-intervention at a median of 22 days (range 11-315). Five patients had stent revision and were able to tolerate oral intake. Two patients had percutaneous endoscopic gastrostomy/jejunostomy insertion. One patient required surgical diversion for persistent obstruction. Complications included stent migration and post-stent insertion bacteremia due to food bolus obstruction. Recurrent malignant GOO in patients with post-surgical anatomy treated with simultaneous endoscopic enteral stenting of afferent and efferent jejunal limbs has a high rate of technical and clinical success and low rate of complications and provides effective palliation.

Predicting hospice appropriateness for nursing home residents with dementia in Korea: A systematic review approach

Background: Korea is one of the fastest aging societies; the number of elderly who die due to Alzheimer dementia has increaseddramatically. The benefits of hospice care were recognized in effective pain management, advance-care planning, decreasedhospitalization, decreased aggressive treatment, and increased job satisfaction. To estimate life expectancy of residents withdementia precisely is difficult, exacerbating the ability to provide palliative care for residents with dementia. However, theunderuse of hospice care in nursing homes (NHs) is a major problem in Korea. Few researchers have identified the needs ofpeople dying with dementia in NHs in Korea. The purpose of this paper was to review and discuss hospice-eligibility assessmenttools. Methods: Four tools were available for discussion at the point of investigation: the Functional Assessment Staging Scale,Alzheimer’s Hospice Placement Evaluation Scale, Advanced Dementia Prognostic Tool from the U.S. Hospice Medicare guidelines,and Global Deterioration Scale. Results: Major problems are underuse of hospice care and lack of guidelines to assess hospice in patients with dementia inKorea. Conclusion: Successfully categorizing elders with dementia as hospice enrollees in Korea will improve the quality of end-of-lifecare for increasing numbers of elders with dementia and their family members.

P32 Talking whilst there’s time

IntroductionHelp the Hospices encourages us to develop the roles of volunteers by ‘building on existing practice, promoting excellence in the future and exploring new approaches to volunteering.’ (Volunteers: Vital to...

“It's Not All Doom and Gloom”: Perceptions of Medical Students Talking to Hospice Patients

End-of-life care has become a priority in medical education internationally. A previous study of hospice patients and staff regarding medical students teaching in a hospice showed positive responses from patients and hospice staff. However concern was expressed by some staff regarding medical students' welfare, contributing to gatekeeping by professionals. Studies have shown that medical students feel underprepared to care for the dying by the time they qualify. The study's objective was to explore in more detail the views and experience of medical students who had spoken with patients during their hospice placement. This was a qualitative study. The study was carried out with 14 Hull York Medical School (HYMS) students who had responded in an electronic survey that they had spoken with patients during their hospice placement. Semistructured interviews provided the study's data. Although students expressed some anxieties prior to their hospice visit about meeting patients who were near the end of life, they felt that the overall experience, and the time spent with patients in particular, provided valuable learning about palliative care and preparation for caring for dying patients. We would encourage staff to not be overprotective but to support students to take every opportunity to meet with patients in a hospice.

Starting out - Hospice placement reminded me that nursing is about caring

Student experiences in the real world of nursing

Hospice placement reminded me that nursing is about caring.

I did not expect to learn much during my two weeks in the day hospice. Indeed, I was unsure what a nurse could do in such an environment. I had a vague impression that there would be arts and crafts, and people passing the time.

Starting out - Hospice placement gave me new perspective on hospital care

Starting out - Hospice placement gave me new perspective on hospital care

Seven Words

On Being a Doctor16 February 2010Seven WordsPaul Rousseau, MDPaul Rousseau, MDFrom Medical University of South Carolina, Charleston, SC 29425.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-4-201002160-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Tommy was just 23 years old, yet he was dying. He was diagnosed with muscular dystrophy at a young age and soon found himself confined to a wheelchair. Now, with the muscular disease suffocating his fragile hold on life, he was near death.Tommy had arrived at the hospital in respiratory distress. Per his request, his mother had decided not to intubate him and place him on a ventilator—he felt he had suffered enough. Although a young man of 23, his wisdom and courage surpassed his years. He soon became comatose, and I was consulted to discuss hospice placement with ... Author, Article, and Disclosure InformationAffiliations: From Medical University of South Carolina, Charleston, SC 29425.Corresponding Author: Paul Rousseau, MD, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425; e-mail, [email protected]com. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 16 February 2010Volume 152, Issue 4Page: 261KeywordsCaregiversComaCyclic adenosine monophosphateForecastingHearingHeartMusclesMuscular diseasesMuscular dystrophiesWheelchairs ePublished: 16 February 2010 Issue Published: 16 February 2010 Copyright & PermissionsCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Health Reform Is Toying With LTC Change

Health Reform Is Toying With LTC Change

The Right to Nutrition and Hydration: A Need for Vigilance

Recent public interest in legal cases related to the withdrawal of artificial nutrition and hydration at the end of life, such as the highly publicized Terri Schiavo case (Quill, 2005), have created a climate in which a potentially life-sustaining intervention, such as gastrostomy tube (G-tube) feeding, might be questioned as futile, and even cruel, when suggested for a person with a severe disability experiencing a health crisis. Lack of understanding exists among some in the health care community and among members of the general public (including some guardians and family members) concerning the distinction between managing medical challenges associated with a chronic disability and providing care at what might be mistakenly perceived to be the end of life (King, 2005). This can have potentially devastating consequences. As suggested by Pugh (2005), the distinction between living with a disability and a terminal illness may be become ‘‘blurred’’ (p. 35), and treatment routinely provided individuals with a disability, such as Gtube feeding, might be denied as futile. The result may be an otherwise preventable death (Turnbull, 2005a).

Determining Appropriate Guidelines for Enrollment into Hospice in the Severely Demented Nursing Home Patient

Introduction/Objective: The diagnosis of dementia is under-recognized for hospice enrollment. In the past few years, multiple studies have suggested that Medicare guidelines are actually not helpful or accurate in assessing patients for hospice placement (1-6). This study is an extension of the work completed by Mitchell et al (2004), comparing guidelines put forth by Medicare versus Mitchell for the enrollment of demented patients in nursing homes into hospice programs.

Starting out - A hospice placement gave me experience of ‘real nursing’

Starting out - A hospice placement gave me experience of ‘real nursing’