Search

Background: As life expectancy has increased, the age at which people are dying has also increased. There is limited knowledge of the experience of dying of the very old. We sought to examine the last 3 days of life for the very old, dying in a palliative care unit, focusing upon symptom burden and medications prescribed. Methods: A retrospective review of medical records of consecutive patients who died in two inpatient palliative care units. Information collated included demographic and medical information, symptom data, and medications (opioids, benzodiazepines and antipsychotics) administered. Analysis comparing patients aged 80 years and older (cases) and those in the median age range of the treating palliative care units, that is, those aged 50 to 70 years (comparators) were conducted. Results: One hundred five cases and 100 comparators were identified. Analysis revealed a significantly shorter length of stay in the cases (13 days) compared to comparators (19 days; p≤0.01).) In the last 3 days, cases received significantly less parenteral morphine equivalents (82.8 versus 170.5 mg, p<0.05), midazolam (12.1 versus 19.1 mg, p<0.05), and lorazepam equivalents (0.9 versus 2.4 mg, p<0.01). Overall, symptom profiles between the groups were similar. Implications: The very old appear to have a distinct experience of palliative inpatient care with shorter admissions, and lower requirements for medication. Reasons for lower medication requirements are discussed, and the need for future prospective studies in this area is highlighted. A better understanding of the needs of this population at end of life will enable adequate service planning and improved care. [ABSTRACT FROM AUTHOR]

Background: An increased demand for palliative care services has been demonstrated, in part due to an aging population and an enhanced role of palliative care in nonmalignant illness. In particular, there is a demand for inpatient palliative care unit beds, with several services now creating waiting lists for admission. The aim of this study was to explore the development, implementation, and outcomes following the introduction of an inpatient palliative care admission triage tool. Methods: The study consisted of two phases: (1) a developmental phase, in which a purposive-sampled group participated in a series of semistructured discussions to determine the clinical and administrative criteria relevant for consideration of admission priority and (2) an implementation and evaluation phase. This second phase consisted of a 3-month trial of the tool at two inpatient palliative care units (involving three separate campuses), with subsequent evaluation of quantitative and qualitative data related to admission processes. Results: Of the 234 patients, there was a suggestion that those with less urgent needs indicated by a low admission score spent more time on the waiting list. Subsequent qualitative analysis demonstrated acceptance of the tool by clinicians, who stated it supported the decision-making processes, and was a useful education aid. Conclusion: This study represents the first reported attempt to define the priorities for a waiting list for admission to palliative care units, and demonstrates its utility in providing a transparent process for palliative care units to manage the competing needs of patients referred for care. [ABSTRACT FROM AUTHOR]

Current evidence suggests that patients with hematological malignancies less frequently access palliative care services, and for those who do, this tends to occur later in their illness than their counterparts with solid malignancies. These patients are also more likely to die in hospital following escalating interventions. This approach to care that considers palliative care referral after most treatments are exhausted has implications for the quality of palliative care intervention possible. An episodic approach engaging palliative care according to needs rather than prognosis may be more valuable. The successful integration of palliative care into the care of hemato-oncological patients requires recognition by palliative care physicians of the particular issues encountered in care, namely, the difficulty in individual prognostication; ongoing therapeutic goals of curability or long term survival; the technical nature and complications of treatment; the speed of change to a terminal event; the need for pathology testing and transfusion of blood products as death approaches; the potentially reversible nature of intercurrent events such as infection; and the long relationships that develop between patients and their hematologists. Meanwhile, hematologists should be aware of the benefits of palliative care earlier in an illness trajectory and that palliative care does not equate to terminal care only. This review summarizes current practices and barriers to referral, and suggests recommendations for collaborative care and further research in the palliation of hemato-oncological patients. In doing so, it highlights to palliative care and hematology physicians how successful integration of their disciplines may improve their care of these patients. [ABSTRACT FROM AUTHOR]

Background: Cystic fibrosis (CF) is a life-limiting congenital disease, with most patients dying at a young age of progressive lung disease. Lung transplantation offers hope for many but may not occur. There is little to guide the provision of palliative care to this young population who maintain hope in the possibility of lung transplantation. Methods: To inform the development of an appropriate model of palliative care, a medical record review of CF patients dying within a 5-year period without lung transplantation was undertaken. The aspects of care that were preventative, therapeutic, or palliative were quantified. Results: Of the 20 records studied, all died in hospital. Only 15 of patients had a do-not-resuscitate order agreed to more than 1 week prior to death, increasing to 90 at the time of death (median of 2 days before death). Opioids were prescribed for 1 patient (5) at 1 week prior to death, increasing to 85 of patients in the last 24 hours of life (median of 36 hours before death). During the last 24 hours of life, intravenous antibiotics continued in 85, and assisted ventilation in 90 of subjects. Conclusion: We conclude that the circumstances surrounding the death of patients with CF holds challenges for their effective palliative care. CF patients continue life prolonging and preventative treatments until the last hours of life. There is an urgent need to examine palliative care approaches that may usefully coexist with maintaining transplantation options in the end-of-life care of this population. [ABSTRACT FROM AUTHOR]

This brief report describes the cautious but successful use of cyclizine, an anticholinergic agent, for the relief of intractable nausea in a patient with myasthenia gravis, followed by a review of the available literature. [ABSTRACT FROM AUTHOR]