Use In Palliative Care Settings Research Articles

Potentially inappropriate prescribing in older adults with cancer receiving specialist palliative care: a retrospective analysis of medical records

Abstract Introduction Older adults (≥65 years) with cancer often have existing comorbidities requiring multiple medications (1). Optimising medications in palliative care requires clinicians to consider whether each medication is appropriate in relation to patients’ context, treatment goals and life expectancy. The reported prevalence of potentially inappropriate prescribing (PIP) in general palliative care settings ranges from 15 to 92% (2). However, the application of tools that are specific to populations with limited life expectancy has been lacking in previous research (2). Aim To describe and assess the appropriateness of prescribing practices for older adults with cancer in the last seven days of life in an inpatient palliative care setting. Methods This was a retrospective observational study of medical records for older adults (≥65 years) with cancer who received inpatient specialist palliative care services in a hospice setting in Ireland in the final week of life over a two-year period. Data were extracted relating to patient demographics and prescribed medications using an electronic pro-forma. Medication appropriateness was assessed using the following tools: STOPPFrail (Version 2; consists of 25 deprescribing criteria for use in frail older adults with limited life expectancy), the OncPal deprescribing guideline (consists of eight medication classes for deprescribing in palliative patients with cancer) and criteria for identifying Potentially Inappropriate Prescribing in older adults with Cancer receiving Palliative Care (PIP-CPC; consists of 24 criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer). These tools were retrospectively applied to the extracted data by the lead researcher. Data were analysed (Stata, Version 15) using descriptive statistics, including means (standard deviation, SD), medians (inter-quartile range, IQR) and frequency and percentage. Results One hundred and eighty older adults with cancer were included in this study. The majority were male (60.6%) and the median age was 74 years (range 65-94 years). The most common primary cancer diagnoses affected the digestive organs (31.7%), respiratory and intrathoracic organs (18.8%) and male genital organs (10%). Almost all patients (94.5%) had at least one comorbid condition (median 3, IQR 2-5). The median number of medications increased from five (IQR 3-7) seven days before death, to 11 medications on the day of death (IQR 9-15). The most prevalent drug classes were opioids, antipsychotics, antispasmodics, benzodiazepines and paracetamol. More than half of patients had at least one PIP identified by the tools (n=97, 53.9%). The identified prevalence of PIP per tool in the patient cohort was: STOPPFrail V2 (20.6%), OncPal (12.7%), PIP-CPC (32.8%). However, several criteria could not be applied due to the absence of clinical information. Conclusion This study highlights that the number of medications prescribed to older adults with cancer increased as time to death approached, and that more than half of patients received at least one medication which was considered potentially inappropriate during their last week of life. The absence of electronic prescribing records and retrospective nature of the study limited the applicability of some criteria. Interventions are needed to optimise medication prescribing and use in palliative care settings. References (1) Sharma M, Loh KP, Nightingale G, Mohile SG, Holmes HM. Polypharmacy and potentially inappropriate medication use in geriatric oncology. J Geriatr Oncol. 2016;7(5):346-53. (2) Cadogan CA, Murphy M, Boland M, Bennett K, McLean S, Hughes C. Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review. Expl Res Clinic Soc Pharm. 2021;1(3):100050.

Virtual Reality Therapy in Palliative Care: A Case Series.

Virtual reality (VR) opens a variety of therapeutic options to improve symptom burden in patients with advanced disease. Until to date, only few studies have evaluated the use of VR therapy in the context of palliative care. This case series aims to evaluate the feasibility and acceptability of VR therapy in a population of palliative care patients. In this single-site case series, we report on six palliative care patients undergoing VR therapy. The VR therapy consisted of a one-time session ranging between 20 to 60 minutes depending on the patient's needs and the content chosen for the VR sessions. A semi-structured survey was conducted and the Edmonton Symptom Assessment System (ESAS) and the Distress Thermometer were performed pre- and post-intervention. Overall, VR therapy was well accepted by all patients. Five out of six patients reported having appreciated VR therapy. There were individual differences of perceived effects using VR therapy. The semi-structured survey revealed that some patients felt a temporary detachment from their body and that patients were able to experience the VR session as a break from omnipresent worries and the hospital environment ("I completely forgot where I am"). There was a considerable reduction in the total ESAS score post-treatment (T0 ESASTot = 27.2; T1 ESASTot = 18.8) and a slightly reduction in distress (T0 DTTot = 4.4; T1 DTTot = 3.8). However, two patients were more tired after the intervention.Significance of Results: Our preliminary results demonstrate that VR therapy is acceptable, feasible and safe for use within a palliative care population and appears to be a viable treatment option. Clinical trials are both warranted and necessary to confirm any therapeutic effects of VR therapy, as is the need to tailor VR systems better for use in palliative care settings.

Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians\u2019 and nurse practitioners\u2019 perceptions

BackgroundThe Liverpool care pathway for the dying patient (LCP) is a multidisciplinary tool developed for the dying phase for use in palliative care settings. The literature reports divergent experiences with its application in a nursing home setting related to its implementation and staff competencies. The aim of this study is to understand how the LCP is being used in the context of the nursing home, including for residents with dementia, and experienced from the perspectives of those responsible for medical treatment in nursing homes.MethodsA mixed-methods approach was used, consisting of a survey followed by interviews. A link to a 9-item online survey with closed and open-ended questions was emailed to all physicians and nurse practitioners of 33 care organisations with nursing homes in three regions of the Netherlands (North, West and South). In addition, 10 respondents with particularly positive or negative experiences were selected for semi-structured interviews.ResultsThe survey was completed by 159 physicians and nurse practitioners. The respondents were very positive on the content and less positive on the use of the LCP, although they reported difficulties identifying the right time to start the LCP, especially in case of dementia. Also using the LCP was more complicated after the implementation of the electronic health record. The LCP was judged to be a marker of quality for the assessment of symptoms in the dying phase and communication with relatives.ConclusionAn instrument that prompts regular assessment of a dying person was perceived by those responsible for (medical) care to contribute to good care. As such, the LCP was valued, but there was a clear need to start it earlier than in the last days or hours of life, a need for a shorter version, and for integration of the LCP in the electronic health record. Regular assessments with an instrument that focusses on quality of care and good symptom control can improve palliative care for nursing home residents with and without dementia.

An Overview of the Bonny Method & Its Use in Palliative Care Settings

The Bonny Method of Guided Imagery and Music (Bonny Method) is a therapeutic treatment and approach that facilitates an environment where a client may gain personal insight and support related to critical life issues and/or concerns. It is a deeply integrative practice, which can also be reconstructive. Conceived by Dr. Helen Bonny, the Bonny method typically utilizes tailored sequences of Western classical music programs that are distinctly designed to stimulate/sustain imagery connected to unconscious feelings and memories. This paper encompasses an introduction to the Bonny Method and guidelines for implementation of this technique in palliative care environments, to allow readers that may be new to the Bonny Method, the opportunity to fully appreciate the collection of papers in this special issue of Music and Medicine. As the Bonny Method allows for deep reflection often within a short time frame, it is well suited for persons at end-of-life, as it may aid in easing psychological pain. In providing emotional release and exploration, it may serve as a comfort for pain and physical symptoms through providing a means of visualizing aspects of illness that may facilitate insight, control, and/or hope. Contraindications for use, and adaptations of the Bonny Method in palliative settings are also examined as a means of grounding implementation practices in the reality of palliative/medical settings. Keywords: guided imagery, Bonny method, music, palliative care, imagery, psychological pain, emotion.GermanDie Bonny Methode GIM und die Arbeit in der palliativen VersorgungAmy Clements-CortésAbstractDie Bonny Methode der Guided Imagery and Music ist eine therapeutische Methode, die eine Umgebung zu erleichtern vermag, in der der Patient persönliche Einsichten und Unterstützung darin gewinnen kann, wie er mit kritischen Lebensumständen u/o Befürchtungen umgehen kann. Dies ist eine tief integrierende und auch wieder aufbauende Arbeit. Die Bonny Methode, von Dr. Helen Bonny entwickelt, benutzt typischerweise zugeschnittene Sequenzen aus westlicher klassischer Musik; diese werden gezielt zusammengestellt, um innere Bilder,verbunden mit unbewussten Gefühlen und Erinnerungen, zu stimulieren bzw. zu unterstützen. Dieser Artikel umfasst eine Einleitung in die Bonny Methode und Guidelines, um diese Technik in palliativen Einrichtungen einzubeziehen. Damit eröffnet sie den in der Bonny Methode unerfahrenen Lesern die Möglichkeit, die Sammlung der Artikel in dieser speziellen Ausgabe von Music and Medicine als gesamtes würdigen zu können. Da die Bonny Methode oft eine tiefe Reflektion innerhalb eines kurzen Zeitrahmens ermöglicht, ist sie sehr geeignet für Menschen am Ende ihres Lebens, weil sie dabei helfen kann, psychischen Schmerz zu lindern. Sie vermittelt emotionales Loslassen und Explorieren; deshalb kann sie dazu dienen, Schmerz und physische Symptome zu beruhigen, indem sie Aspekte einer Krankheit visualisiert und damit Einsicht, Kontrolle und/oder Hoffnung erleichtert. Auch werden Kontraindikationen für die Anwendung und Adaptierung der Bonny Methode in die palliative Versorgung untersucht als ein Mittel, die Praktiken zu deren Einbeziehung in die Realität palliativer/medizinischer Settings zu verankern.Keywords: Guided Imagery, Bonny Methode, Musik, palliative Versorgung, Imagery, psychischer Schmerz, Emotion.Japaneseボニー式の概観と緩和ケアにおける使用ボニー式GIM（ボニーメソッド）は療法的な処置かつアプローチであり、対象者が人生における重大な問題や心配事に関連した支援と自己洞察力を得られる可能性のある環境を作り出す。それは深く多様な要素を全体に組み合わせた実践であり、再現可能なものでもある。ヘレン・ボニーによって考案されたボニーメソッドでは、概して、無意識下の感情と記憶をイメージに結びつけることを刺激・持続させるために明確にデザインされた、適切な一連の西洋クラシック音楽プログラムを使用する。本稿は、緩和ケアにおけるこの技法の導入のためのボニーメソッド概論とガイドラインを包含している。ボニーメソッドが度々短い時間内で深い内観を可能にすることから、精神的苦痛緩和を支援する可能性があり、末期患者に十分適している。情動面での解き放ちと探求を提供する中、疾病の様相を可視化する手段を通して、自己洞察、自己コントロール、時には希望を促進し、苦痛と身体的症状を和らげる可能性がある。緩和・医療現場の状況下での実践の実施を基づかせる目的での使用においての禁忌、そして緩和ケアにおけるボニーメソッドの適合についても考察されている。 キーワード：誘導イメージ療法、ボニー式、音楽、緩和ケア、イメージ、精神的苦痛、感情Chinese 在邦尼式引導想像音樂治療法(GIM)所營造出的環境中，個案能獲得對個人關鍵性議題與困境的覺察與支持。這是一個融合式的方法，也能夠被重新被建構。由海倫‧邦尼博士所構想出的邦尼方法通常是利用為了激發出連結潛意識裡的感受及記憶的想像所特別量身制訂的一系列西方古典音樂。本期音樂與醫學特刊集結多篇文章，讓邦尼方法的入門讀者能充分領略，本文則包含了對邦尼方法的介紹及其技巧在安寧療護環境上的實務應用準則。邦尼方法能夠讓人在短時間內深刻的反思，因此很適合用來幫助生命末期的人減緩心理上的痛苦。在提供情緒紓解與探索的同時，它也可能透過將各層面的疾病視覺意象化來促進病人的洞察力、控制感與/或帶來希望，舒緩生理上的疼痛與症狀。為了在安寧醫療機構實際使用邦尼方法做為穩定病人的介入方式，本文也討論了使用上的禁忌以及在安寧療護/醫療場域做出的調整。Korean3. 완화 의료 환경에서의 Bonny의 GIM 기법과 적용에 대한 개괄Amy Clements-Cortés초록Bonny의 유도된 심상과 음악 기법 (Bonny기법)은 내담자가 삶의 문제 및 염려와 관련해 개인적인 통찰력과 지지를 얻을 수 있는 환경을 구축하도록 도와주는 치료 기법이자 치료 적용법이다. 이는 매우 통합적이며 복원적인 임상분야이다. Dr. Helen Bonny가 구상한 Bonny기법은 무의식적인 감정 및 기억과 관련된 심상을 자극하고 유지하기 위해 의도적으로 구성된 클래식 음악 프로그램을 활용한다. 본 논문은 Bonny기법이 생소한 독자들에게 이번 Music & Medicine 특별 호의 여러 논문들을 깊이있게 이해할 수 있도록 돕기 위해 Bonny기법 및 기술들을 완화의료 환경에서 사용하는 데 필요한 지침들을 소개한다. Bonny기법은 짧은 시간 내에 심층적으로 생각할 수 있게 해주고, 심리적 고통을 완화시키는 데 도움을 줄 수 있기 때문에 말기 환자에게 적합하다. 음악과 심상을 통한 정서적 해방과 탐구를 제공할 때, 통찰력, 통제, 희망 등을 촉진시킬 수 있고, 질병의 다양한 양상을 시각화시키는 수단을 제공함으로써 고통과 신체적 증상들을 완화시켜주는 역할을 한다. 완화 의료 환경내 실제적인 적용에 있어 고려해야 하는 주의점 및 수정 기법에 대한 내용들도 심층적으로 다룬다. 키워드: 유도된 심상, Bonny기법, 음악, 완화 의료, 심상, 심리적 고통, 정서

Development of a brief measure of generativity and ego-integrity for use in palliative care settings.

Our aim was to develop and test a brief measure of generativity and ego-integrity that is suitable for use in palliative care settings. Two measures of generativity and ego-integrity were modified and combined to create a new 11-item questionnaire, which was then administered to 143 adults. A principal-component analysis with oblique rotation was performed in order to identify underlying components that can best account for variation in the 11 questionnaire items. The two-component solution was consistent with the items that, on conceptual grounds, were intended to comprise the two constructs assessed by the questionnaire. Results suggest that the selected 11 items were good representatives of the larger scales from which they were selected, and they are expected to provide a useful means of measuring these concepts near the end of life.

Palliative Care and Use of Animal-Assisted Therapy

A growing body of research and clinical reports support the benefits of utilizing animal-assisted therapy (AAT) as a complementary, transdisciplinary treatment intervention in medical settings. However, fewer articles are found demonstrating AAT's use in palliative care settings. This article is a study of the effects of AAT in palliative care situations, presenting one anecdotal clinical vignette. In this way, the efficacy of this technique in decreasing patient pain, thereby increasing patient quality of life, and lowering staff stress levels may be illustrated.

Physician-Reported Corticosteroid Therapy Practices in Certified Palliative Care Units in Japan: A Nationwide Survey

Although corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer, few studies have addressed nationwide physician-reported practices and attitudes toward corticosteroid therapy in palliative care settings. To clarify physician-reported practices and attitudes toward corticosteroid therapy for anorexia, fatigue, and dyspnea, a 15-item questionnaire was mailed to all 178 certified palliative care units in Japan. In total, 124 physicians returned questionnaires (response rate of 70%). The median percentage receiving corticosteroids among all terminally ill cancer inpatients was 80% (fatigue, 80%; anorexia, 80%; dyspnea, 80%). Physicians reported varying methods and attitudes regarding corticosteroid use in palliative care settings. Regarding withdrawal when patient death was imminent, 46% of respondents usually abruptly ceased corticosteroid use, while 33% reduced but did not stop administration, and 21% neither stopped nor reduced corticosteroids. As for dosage, 47% of physicians selected a minimum daily dose for fatigue <2 mg, while 51% chose 2-4 mg. As for administration period, 50% started administering corticosteroids for dyspnea regardless of the prognosis, while 30% regarded a predicted survival of less than 3 months to be an indication for corticosteroid treatment. For side effect management, 48% did not principally prescribe corticosteroids for patients with hyperactive delirium, while 44% cautiously prescribed corticosteroids. The use of corticosteroids is very common in Japanese palliative care units, but physicians reported varying practices and attitudes regarding administration protocols. Future studies are needed to determine the standard treatment protocol for corticosteroid use in the terminally ill.

Evaluating an adapted mindfulness meditation course for use in palliative care setting

IntroductionMindfulness Meditation involves paying attention to our mind and body moment by moment, being aware of what arises without judgement.Experience and evaluation demonstrated that some patients receiving one to one...

The Pattern of Antimicrobial Use for Palliative Care In-Patients During the Last Week of Life

In terminally ill cancer patients approaching the dying phase, liberal use of antimicrobials is often viewed by palliative care experts as irrational. No previous reports have reviewed current antimicrobial use in palliative care settings in Saudi Arabia. The objective of this study was to explore the pattern of antimicrobial use in a tertiary palliative care unit (TPCU) during the last week of patients' life. Medical records of all patients who died in the TPCU over a 14-month period were reviewed for demographics as well as the frequency and rationale of antimicrobial use during the patients' last week of life. Information on antimicrobial use was obtained from a computerized pharmacy database. Of 138 patients who died with advanced cancer in the TPCU, 87 (63%) were on one or more antimicrobials during their last week of life. Antibiotics were more frequently used as compared to antifungal and antiviral agents, 64 (46.4%); 45 (32.6%); and 2 (1.5%), respectively. About one third (31.3%) of patients who received antibiotics during their last week of life were prescribed more than one antibiotic. Antimicrobials were mostly given systemically (79%) rather than topically (21%). The most common rationales for antimicrobial prescribing were oral thrush in 36 patients (25.4%), wound care in 29 patients (20.4%), and on empirical basis in 29 patients (20.4%). The current practice of antimicrobial prescribing, especially for patients who are eminently dying, may need to be reviewed. Initiation of antimicrobial treatment in this group of patients should be based on clear treatment goals and desired outcomes, considering views of patients and families.

Caregiver satisfaction with out-patient oncology services: utility of the FAMCARE instrument and development of the FAMCARE-6

To evaluate caregivers' experience of oncology services for ambulatory patients and to develop a short instrument (FAMCARE-6) suitable for computerised administration in the clinical setting. A sample of 234 caregivers recruited from 388 ambulatory oncology patients completed a computerised version of the 20-item family satisfaction with advanced cancer care (FAMCARE) instrument, which was originally developed for use in palliative care settings. Caregivers reported generally high satisfaction with all aspects of ambulatory oncology services: overall score; mean, 3.96 (SD, 0.67); information giving, 3.88 (0.78); physical patient care, 4.00 (0.71); availability of care, 3.89 (0.77); and psychosocial care, 4.05 (0.72), from a possible score of 5. Factor analyses identified a single factor structure; the items were reduced to six (FAMCARE-6), which yielded a scale with adequate psychometric properties (completion rates over 90% for every item, correlation of 0.7 or above with the factor identified in the individual item factor analysis, and internal reliability of α = 0.85). The overall mean score was 3.91 (SD, 0.73) for the FAMCARE-6. FAMCARE-6 can be used to assess caregiver satisfaction with ambulatory oncology services and may be suitable to be included as part of a computerised screening system for the psychological care of oncology patients.

Instruments for assessing quality of life in palliative care settings.

Quality of life is an outcome that is particularly important during palliative care. However, in order to measure this outcome, it is necessary to have a valid and reliable measure. The purpose of the article was to identify and describe quality of life measures that are appropriate for use in palliative care settings. Characteristics that are believed to be critical for quality of life instruments include the following. The instrument should: (1) be multidimensional; (2) provide self-report data; (3) be useful in the setting in which it is to be used; (4) be valid and reliable for use in palliative care settings. The five scales described measure a variety of dimensions including physical, psychological, social, spiritual, existential, support, symptoms and functional aspects of quality of life. All but one are self-report instruments. All have evidence of validity and reliability for use with palliative care populations.

Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group.

OBJECTIVES: To develop an outcome measure for patients with advanced cancer and their families which would cover more than either physical symptoms or quality of life related questions. To validate...