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For patients desiring end-of-life care in a palliative care unit, ensuring a safe and timely transfer while reducing length of stay in acute care is optimal. A chart review of 130 patients was completed on those who either died in acute care or were transferred to a palliative care unit. In all, 31% of patients died in acute care and 69% were transferred to a palliative care unit. Barriers impacting a timely transfer included disposition planning, behavioural changes requiring monitoring, imminently dying patients and those awaiting medical assistance in dying. This article makes clinical recommendations to address these barriers.

Background: Patients approaching end of life may experience intractable symptoms managed with palliative sedation. The legalization of Medical Assistance in Dying (MAiD) in Canada in 2016 offers a new option for relief of intolerable suffering, and there is limited evidence examining how the use of palliative sedation has evolved with the introduction of MAiD. Objectives: To compare rates of palliative sedation at a tertiary care hospital before and after the legalization of MAiD. Methods: This study is a retrospective chart analysis of all deaths of patients followed by the palliative care consult team in acute care, or admitted to the palliative care unit. We compared the use of palliative sedation during 1-year periods before and after the legalization of MAiD, and screened charts for MAiD requests during the second time period. Results: 4.7% (n = 25) of patients who died in the palliative care unit pre-legalization of MAiD received palliative sedation compared to 14.6% (n = 82) post-MAiD, with no change in acute care. Post-MAiD, 4.1% of deaths were medically-assisted deaths in the palliative care unit (n = 23) and acute care (n = 14). For patients who requested MAiD but instead received palliative sedation, the primary reason was loss of decisional capacity to consent for MAiD. Conclusion: We believe that the mainstream presence of MAiD has resulted in an increased recognition of MAiD and palliative sedation as distinct entities, and rates of palliative sedation increased post-MAiD due to greater awareness about patient choice and increased comfort with end-of-life options.

Introduction Medical assistance in dying (MAID) was legalized in Canada in 2016. We aimed to characterize the prevalence of psychiatric comorbidity among MAID requesters in order to enhance clinicians' awareness of the potential for psychiatric needs among MAID requesters. Methods Using chart review, we retrospectively abstracted demographic, clinical, and psychosocial variables of MAID requesters at our institution, a 638-bed tertiary care center in Toronto, Canada. Patients requesting MAID between June 2016 and April 2019 were included. Psychiatric comorbidity was the primary dependent variable. Results 155 patients requested MAID during the study period. Among them, 60 (39%) had documented psychiatric comorbidity, most commonly depression (n=44; 73%). Severe mental illness accounted for 10 cases (6.5% of the total sample). Among patients with psychiatric comorbidity, 25 (41.7%) had at least one MAID eligibility assessment conducted by a psychiatrist, compared to 16 (16.8%) patients without psychiatric comorbidity (χ2=11.649, df=1, p=0.001). Among the 10 patients with severe mental illness (SMI), a psychiatrist conducted a MAID eligibility assessment in 8 patients (80%), compared to 17 patients (34%) without SMI (χ2=7.255, df=1, p=0.007). Conclusion Patients with psychiatric comorbidity comprise a substantial proportion of patients requesting MAID. These findings highlight the importance of recognizing the psychiatric needs of MAID requesters and involving psychiatry in MAID assessments when warranted. A gap still exists in understanding which factors are most important in determining the need for psychiatric involvement in MAID assessments. We propose recommendations borne from our clinical experience.

Background Bill C-14, the legislation that legalized medical assistance in dying (MAiD) in Canada in 2016, outlines eligibility criteria and includes both a mandated 10-day reflection period and a requirement that the patient have capacity to consent at the time MAiD is provided. We examined clinical factors associated with shortened reflection periods or loss of capacity before provision of MAiD. Methods This retrospective database review involved patients who requested MAiD at a tertiary care hospital in Toronto, Canada, between June 2016 and April 2019. We used logistic regression analyses to examine the association between the combined outcome of unanticipated loss of decisional capacity, shortening of the reflection period or death and the clinical risk factors of interest (age, sex, location of MAiD request [inpatient v. outpatient], score on palliative performance scale [PPS] and diagnosis [cancer v. noncancer]). We generated receiver operating characteristic curves to identify the PPS score (encompassing 5 functional domains: ambulation, activity level, self-care, intake and level of consciousness) that best predicted loss of capacity, shortening of the reflection period or death. Results In total, 155 patients requested assessment for MAiD, and 136 of these were included in the statistical analyses. For 68 patients, the reflection period was not shortened; the other 68 patients lost capacity, died or required shortening of the reflection period. In contrast to the results for age, sex, location of request and diagnosis, the PPS score was associated with loss of capacity or shortening of the reflection period (odds ratio 4.63, 95% confidence interval 2.87-8.23, per 10-point decrease in PPS score). PPS scores less than or equal to 40% balanced sensitivity, specificity and negative predictive value while emphasizing sensitivity to prevent false negative errors. Interpretation The PPS score at the time of MAiD request was strongly associated with loss of capacity or shortening of the reflection period, with lower scores incrementally increasing the risk of these outcomes. For patients with a PPS score of 40% or below, close monitoring is warranted, potentially with plans made to allow rapid provision of MAiD should their clinical condition deteriorate.

The end-of-life (EOL) experience of patients dying in acute care has been highlighted as an area for quality improvement. Delivering comprehensive care to these patients involves addressing physical symptoms and psychosocial concerns. The social work role offers a range of interventions to address the common domains of EOL care. We report on results of an EOL survey evaluating satisfaction with social work interventions for imminently dying patients in acute care. This article is the first phase towards gaining an understanding of the contributions of the social worker in supporting dying patients and their families within our organisation.

Fatigue or tiredness is one of the most commonly reported symptoms in breast cancer patients treated with radiation therapy (RT). This study aimed to identify characteristics associated with fatigue in breast cancer patients receiving adjuvant RT.Patients with non-metastatic breast cancer receiving RT at the Odette Cancer Centre from 2011 to 2017 were included in our study if they completed at least one ESAS pre- and post-RT. Information regarding patient, disease and treatment characteristics was retrieved from chart review. To identify variables associated with fatigue scores pre-RT, post-RT and changes in fatigue scores, a univariate and multivariate general linear regression analysis was conducted; p 0.05 was considered statistically significant.Our study included 1223 female patients (mean age 59 years old) who completed ESAS on average 28 days before, and 142 days after RT. In multivariate analysis, higher baseline fatigue scores were found in women with higher disease stages (p = 0.001), and those who receive locoregional radiation (p 0.001). No variables were significantly associated with post-RT fatigue scores. While adjuvant chemotherapy and locoregional RT were associated with higher baseline scores in univariate analysis, in multivariate analysis, they were associated with significant reduction in fatigue post-RT (p = 0.01, p = 0.007 respectively).Fatigue is associated with higher disease stage and receipt of locoregional radiation. While the relationship between anxiety or depressive symptoms and fatigue is well-established, a major gap exists in our understanding of its etiology and treatment; further investigation to address this can better improve patient quality of life.

Context Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced cancer. Symptom management for patients with end-stage MBO can be challenging, especially when venting gastrostomy is contraindicated. Percutaneous transesophageal gastrostomy (PTEG) is an alternative option allowing safe and effective symptom management in palliative care patients. Objectives We describe our experience with an initial series of 10 patients with MBOs refractory to medical management who received PTEG for gastrointestinal decompression, with a focus on palliative outcomes and safety. Methods We retrospectively reviewed the charts of 10 patients with advanced malignancy and associated gastrointestinal obstruction who received PTEG for symptom management between March 2018 and November 2018. We report on patient diagnosis, indications for PTEG, outcomes after insertion, and any associated morbidity and mortality. Results PTEGs were successfully inserted in all 10 patients with contraindications to a venting gastrostomy. There were no acute postprocedural complications. Median time from PTEG insertion to death was 15 days. Symptoms of MBO improved in all 10 patients, and all were able to resume some degree of oral intake. Importantly, unlike with venting gastrostomies, all patients required suction to maintain resolution of MBO symptoms. Conclusion PTEG should be considered for gastrointestinal decompression in patients with MBO who are not candidates for surgical decompression or standard venting gastrostomy. This safe and effective procedure improves symptom management and quality of life for patients with MBO who are approaching end of life.

Background: In June 2016, the Government of Canada passed Bill C-14 decriminalizing medically assisted death. Increasing numbers of Canadians are accessing medical assistance in dying (MAiD) each year, but there is limited information about this population. Objective: To describe the characteristic outcomes of MAiD requests in a cohort of patients at an academic tertiary care center in Toronto, Ontario, Canada. Methods: A retrospective chart review of patients making a formal request for a MAiD eligibility assessment from July 16 to September 18. Data extracted included demographics, diagnosis, psychosocial characteristics, information relating to the MAiD request, and clinical outcome. Results: We received 107 formal requests for MAiD assessment. Ninety-seven patients were found eligible, of whom 80 received MAiD. Cancer was the primary diagnosis for 78% and median age was 74 years. The majority of patients (64%) cited “functional decline or inability to participate in meaningful activities” as the main factor motivating their request for MAiD. Half of patients who received MAiD (46%) described their request as consistent with a long-standing, philosophical view predating their illness. The 10-day reflection period was reduced for 39% of provisions due to impending loss of capacity. Our cohort was very similar demographically to those described both nationally and internationally. Conclusion: Patients seeking MAiD at our institution were similar to those described in other jurisdictions where assisted dying is legal and represent a group for whom autonomy and independence is critical. We noted a very high rate of risk of loss of capacity, suggesting a need for both earlier assessments and regular monitoring.

Breast cancer patients receiving radiotherapy (RT) commonly report pain, contributing to physical and emotional distress, and potentially resulting in poor quality of life. This study prospectively identified trends and risk factors in patient-reported pain associated with breast irradiation using the Edmonton Symptom Assessment Scale (ESAS) and a study-specific Skin Symptom Assessment (SSA). Before RT and once per week during RT, patients completed the ESAS and SSA. Upon RT completion, patients were contacted via telephone to complete both assessments weekly for 6 weeks, and a final assessment was conducted 1–3 months post-RT. Only data from patients who had completed both assessments before, at least once during, and at least once after RT were included in our analysis. A total of 426 patients provided data for the analysis. Overall acute pain increased significantly at week 1–2 (p

Diphenhydramine (DPH) is an over-the-counter antihistamine medication commonly used for symptom management in palliative care. Despite the ease of access and perceived safety of DPH, there is documented evidence of potential for abuse of this medication. We present a case of a 61-year-old man with metastatic carcinoma of the distal esophagus, who was initially admitted with a pain crisis but subsequently developed a severe DPH withdrawal syndrome consisting of hyperactive delirium, autonomic dysfunction, and increased muscle tone. With careful selection of the antipsychotic agent loxapine, additional symptom management medications and scheduled tapering the patient was able to be discharged home for end-of-life care. We highlight the challenges of recognizing and managing a withdrawal syndrome in patients with terminal illnesses at end of life.

Ovarian cancer is challenging, both physically and psychologically, because of the advanced nature of the disease at diagnosis, adverse effects of the disease and treatment, and impact on roles and responsibilities. The family plays an integral role in promoting and maintaining the health of family caregivers, as well as providing physical and emotional support. The purpose of this study was to explore the experience of family caregivers caring for their loved ones with advanced ovarian cancer. Thirteen family caregivers were interviewed. The analysis of the data revealed 4 significant challenges that characterized the caregiving experience over time: confronting the initial diagnosis, dealing with fluctuations in physical status, confronting a turning point, and facing decline and death. Woven throughout these challenges, family caregivers routinely described difficulties in accessing information and navigating the health care system, which caused them added concern and frustration.

Background Chronic diseases, primarily cardiovascular disease, respiratory disease, diabetes and cancer, are the leading cause of death and disability worldwide. In sub-Saharan Africa (SSA), where communicable disease prevalence still outweighs that of non-communicable disease (NCDs), rates of NCDs are rapidly rising and evidence for primary healthcare approaches for these emerging NCDs is needed. Methods A systematic review and evidence synthesis of primary care approaches for chronic disease in SSA. Quantitative and qualitative primary research studies were included that focused on priority NCDs interventions. The method used was best-fit framework synthesis. Results Three conceptual models of care for NCDs in low- and middle-income countries were identified and used to develop an a priori framework for the synthesis. The literature search for relevant primary research studies generated 3759 unique citations of which 12 satisfied the inclusion criteria. Eleven studies were quantitative and one used mixed methods. Three higher-level themes of screening, prevention and management of disease were derived. This synthesis permitted the development of a new evidence-based conceptual model of care for priority NCDs in SSA. Conclusions For this review there was a near-consensus that passive rather than active case-finding approaches are suitable in resource-poor settings. Modifying risk factors among existing patients through advice on diet and lifestyle was a common element of healthcare approaches. The priorities for disease management in primary care were identified as: availability of essential diagnostic tools and medications at local primary healthcare clinics and the use of standardized protocols for diagnosis, treatment, monitoring and referral to specialist care. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0613-5) contains supplementary material, which is available to authorized users.