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Introduction: Palliative sedation (PS) is an intrusive measure to relieve patients at the end of their life from otherwise untreatable symptoms. Intensive discussion of the advantages and limitations of palliative care with the patients and their relatives should precede the initiation of PS since PS is terminated by the patient's death in most cases. Drugs for PS are usually administered intravenously. Midazolam is widely used, either alone or in combination with other substances. PS can be conducted in both inpatient and outpatient settings; however, a quality analysis comparing both modalities was missing so far.Patients and Methods: This prospective observational study collected data from patients undergoing PS inpatient at the palliative care unit (PCU, n = 26) or outpatient at a hospice (n = 2) or at home (specialized outpatient palliative care [SAPV], n = 31) between July 2017 and June 2018. Demographical data, indications for PS, and drug protocols were analyzed. The depth of sedation according to the Richmond Agitation Sedation Scale (RASS) and the degree of satisfaction of staff members and patient's relatives were included as parameters for quality assessment.Results: Patients undergoing PS at the PCU were slightly younger compared to outpatients (hospice and SAPV combined). Most patients suffered from malignant diseases, and midazolam was the backbone of sedation for inpatients and outpatients. The median depth of sedation was between +1 and -3 according to the RASS with a trend to deeper sedation prior to death. The median degree of satisfaction was "good," scored by staff members and by patient's relatives. Significant differences between inpatients and outpatients were not seen in protocols, depth of sedation, and degree of satisfaction.Conclusion: The data support the thesis that PS is possible for inpatients and outpatients with comparable results. For choosing the best place for PS, other aspects such as patient's and relative's wishes, stress, and medical reasons should be considered. [ABSTRACT FROM AUTHOR]

Purpose: Recent guidelines for prognostic evaluation recommend clinicians’ prediction of survival (CPS) for survival prediction in patients with advanced cancer. However, CPS is often inaccurate and optimistic. Studies on factors associated with overestimation or underestimation of CPS are limited. We aimed to investigate the factors associated with the overestimation and underestimation of CPS in patients with far-advanced cancer. Methods: The current study was a secondary analysis of an international multicenter prospective cohort study, which enrolled newly admitted patients with advanced cancer in palliative care units (PCUs) in Japan, Korea, and Taiwan from 2017 to 2018. We obtained the temporal CPS at enrollment and performed multivariate logistic regression analysis to identify the factors associated with “underestimation (less than 33% of actual survival)” and “overestimation (more than 33% of actual survival).” Results: A total of 2571 patients were assessed and admitted in 37 PCUs between January 2017 and September 2018. Older age (adjusted odds ratio [aOR] 1.01; 95% confidence interval [CI] 1.01–1.02; P < 0.01) and reduced oral intake (aOR 0.68; 95% CI 0.51–0.89; P < 0.01) were identified as significant factors associated with underestimation. Dyspnea (aOR 1.28; 95% CI 1.06–1.54; P = 0.01) and hyperactive delirium (aOR 1.34; 95% CI 1.05–1.72; P = 0.02) were identified as significant factors associated with overestimation. Conclusion: Older age was related to underestimation, while dyspnea and hyperactive delirium were related to overestimation of CPS for patients with weeks of survival. However, reduced oral intake was less likely to lead to underestimation. [ABSTRACT FROM AUTHOR]

Background: In Switzerland, palliative care (PC) clinical training is well established at undergraduate and specialist postgraduate levels. However, postgraduate nonspecialist training curricula are less documented. Local Problem: A structured curriculum for nonspecialist rotation within internal medicine (IM) in specialized PC wards is lacking. Objective: To pilot two versions of a PC nonspecialist curriculum for IM residents in Swiss PC units. Methods: In the pilot phase, two curricula?short immersion (3?10 weeks, based on the University of Toronto's Internal-Medicine PC Rotation) and standard nonspecialist (11?18 weeks, based on the Canadian Society of Palliative Care Physician Competencies)?were assessed using a mixed-method online survey. One university and two nonuniversity sites participated. The analysis was descriptive. Results: Five residents and eight supervisors of five training rotations (July?October 2023) responded. Overall, curriculum quality and feasibility (content and time) received positive ratings across all groups, with high satisfaction concerning organization, educational design, learning support, climate, experience, and facilities. Nonuniversity sites were generally rated more positively than university sites. Qualitative feedback paralleled these findings, highlighting the curriculum's relevance and fit with learners' needs and suggesting potential simplifications and more personalized planning. Conclusions: Establishing short and standard duration curricula for a PC program is viable and well received by nonspecialist trainees. Future implementation should concentrate on personalized learning objectives and streamlining the content and structure of the competencies. Cooperation within various training settings (university and regional hospitals) as well as on an international level (e.g., Canada?Switzerland) may further improve the quality of the proposed training formats.

Abstract Background Several studies deal with the question of what constitutes a "satisfactory death". A smaller number of studies deal with unsatisfactory dying processes. And only a few shed light on unsatisfactory deaths that take place in hospices and palliative care units, which see themselves as places conducive to a "good" death. What also remains largely undiscussed are the ethical aspects that accompany the observation of an unsatisfactory course of death. Method The research was carried out as an exploratory and qualitative study. The data collection and analysis were based on the methods of the "grounded theory". Results Notions of a bad death are articulated here, though hardly by the affected persons and their relatives themselves, but rather by the professionals. Principally, descriptions of unsatisfactory dying processes refer to deficient success in symptom control, whereby the principle of autonomy is of particular importance. The focus here is not only on the needs of patients, but also on the needs of staff. The manifestation of such notions is related to the requirements arising from a practice that apparently evokes a need for accountability in the form of communicative reassurance. Conclusion An idealised definition of "dying well" is in danger of losing sight of the contextual specifics of the practice involved, which can lead to ethically problematic situations.

Aims:The evaluation of swallowing in the palliative care (PC) unit (PCU) is an important indicator of care. In this study, we investigated how an on-admission swallowing test in the PCU guides the course of the feeding route.Methods:This single-center, retrospective study included PC patients who underwent bedside swallowing evaluation. The main exclusion criteria were gastrointestinal failure requiring permanent parenteral nutrition, no swallowing test upon admission, and a length of stay shorter than four days. The primary endpoint was the proportion of patients with dysphagia who transitioned to oral feeding.Results:The study included 63 patients [age, median interquartile range: 80.0 (14) years (37 to 94 years); males: 54.0%]. Thirty-six (57.1%) of 63 admissions had dysphagia, whereas 27 (42.9%) patients had no dysphagia. The route of feeding was modified in 50.8% of the samples during their PCU stay. The proportion of patients who returned to oral feeding was 30.2% (n=19), whereas 6.3% (n=4) and 12.7% (n=8) of the sample underwent nasoenteral tube and percutaneous endoscopic gastrostomy (PEG) placement, respectively. Among the 32 patients who were on tube feeding on admission, 12 (37.5%) returned to oral feeding during their PCU stay. Seven (58.4%) of these subjects who regained oral feeding were on nasoenteral tube feeding and 5 (41.6%) were on PEG feeding on admission.Conclusions:This study showed a high rate of dysphagia on admission to the PCU. On the other hand, safe and adequate oral feeding could be re-initiated in almost one-third of patients with dysphagia on admission.

Background: In Japan, the number of patients with aggressive hematological malignancies (PHMs) admitted at the palliative care unit (PCU) in their end-of-life (EOL) stage was fewer than that of patients with solid tumors due to several reasons. The assessment of patient characteristics and the methods of survival prediction among PHMs in the EOL stage are warranted. Objectives: This study aimed to identify the current medical status and the method of survival prediction among PHMs treated at the PCU. Setting/Subjects/Measurements: We retrospectively analyzed the clinical data of 25 PHMs treated at our PCU between January 2017 and December 2020. The association between survival time and the palliative prognostic score (PAP) and palliative prognostic index (PPI) was analyzed. Results: The average age of the PHMs was higher than that of patients with lung cancer as a control. The median survival time of the PHMs was shorter than the control group. Most PHMs could not receive standard chemotherapy, and the most common cause of death was disease-related organ failure. Significant associations were observed between the survival time and each PAP/PPI value in patients with malignant lymphoma, but not in those with leukemia. Conclusion: The PHMs in the PCU had a lower median survival time than the control group. These results were induced by the result of patient selection to avoid treatment-related severe toxicity. The survival prediction using the PAP and PPI was less accurate in patients with leukemia.

Abstract Background The number of palliative care patients with complex needs is increasing in developed countries. In addition to physical aspects and symptom control, psychosocial aspects are of great importance for palliative care patients. The aim of this study was to understand which psychosocial aspects are important to patients, relatives and health professionals within the setting of a palliative care unit in comparison with specialised palliative home-care (SPHC). Methods We used a qualitative design based on semistructured interviews, which were coded via qualitative content analysis. The study took place in the state of Hesse, Germany, and data collection was conducted in 2017 (interviews from the ELSAH study, which was conducted in a SPHC) and 2018 (supplementary interviews conducted in a palliative care unit). The results from both settings were compared. Results In the palliative care unit, 10 health professionals, 11 patients and 8 relatives were interviewed. In the outpatient setting, we interviewed 30 health professionals, 14 patients and 14 relatives. We identified four key psychosocial issues related to palliative care that were relevant in both the inpatient and outpatient settings: care planning, patient-centred care, a protected environment with feelings of safety, and psychological well-being. In addition, immediate availability of medical staff, greater relief of the relatives and better accessibility of psychological care were more important in the inpatient setting than in the specialised palliative home care setting. Conclusions Knowledge and application of the identified key issues may improve patient-centred palliative care. Accessibility of psychological care and immediate availability of medical staff may be important factors for enhancing psychological well-being in the inpatient palliative care setting. Consideration of the identified key issues may help to develop more collaborative transitions between the palliative care unit and the SPHC and may help to provide palliative care patients and their families with care that is appropriate and feasible for them. Trial registration The underlying comparative study of the outpatient setting of specialised palliative home-care (ELSAH) was registered within the German Clinical Trials Register DRKS-ID: DRKS00012421, ( https://drks.de/search/de/trial/DRKS00012421 ) on 19th May 2017.

Aims: The evaluation of swallowing in the palliative care (PC) unit (PCU) is an important indicator of care. In this study, we investigated how an on-admission swallowing test in the PCU guides the course of the feeding route. Methods: This single-center, retrospective study included PC patients who underwent bedside swallowing evaluation. The main exclusion criteria were gastrointestinal failure requiring permanent parenteral nutrition, no swallowing test upon admission, and a length of stay shorter than four days. The primary endpoint was the proportion of patients with dysphagia who transitioned to oral feeding. Results: The study included 63 patients [age, median interquartile range: 80.0 (14) years (37 to 94 years); males: 54.0%]. Thirty-six (57.1%) of 63 admissions had dysphagia, whereas 27 (42.9%) patients had no dysphagia. The route of feeding was modified in 50.8% of the samples during their PCU stay. The proportion of patients who returned to oral feeding was 30.2% (n=19), whereas 6.3% (n=4) and 12.7% (n=8) of the sample underwent nasoenteral tube and percutaneous endoscopic gastrostomy (PEG) placement, respectively. Among the 32 patients who were on tube feeding on admission, 12 (37.5%) returned to oral feeding during their PCU stay. Seven (58.4%) of these subjects who regained oral feeding were on nasoenteral tube feeding and 5 (41.6%) were on PEG feeding on admission. Conclusions: This study showed a high rate of dysphagia on admission to the PCU. On the other hand, safe and adequate oral feeding could be re-initiated in almost one-third of patients with dysphagia on admission. [ABSTRACT FROM AUTHOR]

Background: The number of palliative care patients with complex needs is increasing in developed countries. In addition to physical aspects and symptom control, psychosocial aspects are of great importance for palliative care patients. The aim of this study was to understand which psychosocial aspects are important to patients, relatives and health professionals within the setting of a palliative care unit in comparison with specialised palliative home-care (SPHC). Methods: We used a qualitative design based on semistructured interviews, which were coded via qualitative content analysis. The study took place in the state of Hesse, Germany, and data collection was conducted in 2017 (interviews from the ELSAH study, which was conducted in a SPHC) and 2018 (supplementary interviews conducted in a palliative care unit). The results from both settings were compared. Results: In the palliative care unit, 10 health professionals, 11 patients and 8 relatives were interviewed. In the outpatient setting, we interviewed 30 health professionals, 14 patients and 14 relatives. We identified four key psychosocial issues related to palliative care that were relevant in both the inpatient and outpatient settings: care planning, patient-centred care, a protected environment with feelings of safety, and psychological well-being. In addition, immediate availability of medical staff, greater relief of the relatives and better accessibility of psychological care were more important in the inpatient setting than in the specialised palliative home care setting. Conclusions: Knowledge and application of the identified key issues may improve patient-centred palliative care. Accessibility of psychological care and immediate availability of medical staff may be important factors for enhancing psychological well-being in the inpatient palliative care setting. Consideration of the identified key issues may help to develop more collaborative transitions between the palliative care unit and the SPHC and may help to provide palliative care patients and their families with care that is appropriate and feasible for them. Trial registration: The underlying comparative study of the outpatient setting of specialised palliative home-care (ELSAH) was registered within the German Clinical Trials Register DRKS-ID: DRKS00012421, (https://drks.de/search/de/trial/DRKS00012421) on 19th May 2017. [ABSTRACT FROM AUTHOR]

Objectives: Although palliative care units treat patients with various comorbidities, there are no reports of patients with obsessive-compulsive disorder (OCD). Methods: The treatment and care of a breast cancer patient with OCD are presented. Results: A woman in her 40s was admitted to the palliative care unit for terminal breast cancer. She spent most of the day cleaning the bath and bed areas, ignoring efforts to restrain her actions by the staff. After being diagnosed with OCD, the above symptoms improved through the coordinated action of the staff and medication. Significance of results: This is the first report of the diagnosis and treatment of a patient with OCD in a palliative care unit. Early psychiatric diagnosis and subsequent staff response contributed to improvement in the patient's quality of life. [ABSTRACT FROM AUTHOR]

A unique structure of care for neurological inpatients with significant palliative care (PC) needs was established in the Department of Neurology at the Charité—Universitätsmedizin Berlin in 2021: a specialized neuropalliative care (NPC) unit. After one year, we provide an overview of the concept and the patients' characteristics. Methods: We retrospectively analyzed the characteristics of patients treated in our NPC unit between February 2021–February 2022. Data were extracted from medical records and PC assessment including diagnosis, mode of admission and discharge, length of stay, and palliative symptoms. Data are presented as averages with a 95% confidence interval [lower limit; upper limit] or percentage (absolute number). Results: We included 143 patients (52% (75) female, 67.9 years [65.6; 70.2]). Patients were admitted from general wards (48%; 68), their homes (22%; 32), intensive care units (16%; 23) or emergency departments (14%; 20). The main diagnoses were tumors of the nervous system (39%; 56), neurodegenerative diseases (30%; 43), neurologic complications (13%; 19) and cerebrovascular diseases (12%; 17). Complaints most frequently rated as severely to overwhelmingly burdensome were motor- or fatigue-associated problems, problems communicating, dysphagia and pain. The average length of stay was 13.7 days [12.2; 15.2]. Forty-five percent (64) of patients were discharged without further PC, 17% (24) were referred to a hospice and 13% (18) were discharged with outpatient PC. Five percent (7) were referred to neurorehabilitation and 21% (30) of patients died. Conclusions: Our NPC unit is a new model of care for neurological patients with substantial PC needs especially within the structures of a highly specialized and individualized medicine. [ABSTRACT FROM AUTHOR]

Purpose: It is important for palliative care providers to identify what factors are associated with a "good death" for patients with advanced cancer. We aimed to identify factors associated with a "good death" evaluated by the Good Death Scale (GDS) score among inpatients with advanced cancer in palliative care units (PCUs) in Japan. Methods: The study is a sub-analysis of a multicenter prospective cohort study conducted in Japan. All variables were recorded on a structured data collecting sheet designed for the study. We classified each patient into better GDS group or worse GDS group, and examined factors associated with better GDS using multivariate analysis. Results: Between January and December 2017, 1896 patients were enrolled across 22 PCUs in Japan. Among them, a total of 1157 patients were evaluated. Five variables were significantly associated with a better GDS score in multivariate analysis: preferred place of death at PCU (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.72–4.71; p < 0.01), longer survival time (OR 1.02; 95% CI 1.00–1.03; p < 0.01), not sudden death (OR 1.96; 95% CI 1.27–3.04; p < 0.01), better spiritual well-being in the last 3 days in life (OR 0.53; 95% CI 0.42–0.68; p < 0.01), and better communication between patient and family (OR 0.81; 95% CI 0.66–0.98; p = 0.03). Conclusions: We identified factors associated with a "good death" using GDS among advanced cancer patients in Japanese PCUs. Recognition of factors associated with GDS could help to improve the quality of end-of-life care. [ABSTRACT FROM AUTHOR]

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Introduction: Since the COVID-19 pandemic, visiting policies in various healthcare centres across the world have changed. Visiting patients by relatives and friends have been stopped or significantly limited. New conditions and legal constraints for family visits had to be implemented also at in-patient palliative care settings, even though accompanying a dying person is crucial for the quality of the end of life. The study aimed to identify and review the visiting policies at in-patient specialist palliative care settings across Central and Eastern Europe. Patients and methods: The study was conducted one year after the COVID-19 pandemic outbreak from May to October 2021. Information about visiting policies, published on official websites of the in-patient specialised palliative care settings (stationary hospices and hospital-based palliative care units) from Central and Eastern European countries, were identified and categorised. The websites which lacked information about visiting policy during the COVID-19 pandemic were excluded. Qualitative and quantitative analysis of the obtained data was conducted by using content analysis techniques and descriptive analysis. The content from websites was translated into Polish with the usage of the Google Translate machine tool. Results: Data from 55 in-patient palliative care settings from 8 countries were collected and analysed (83.6% from Poland, and the other from Bulgaria, Czech Republic, Estonia, Lithuania, Romania, Slovakia and Ukraine). In 43.6% of the organisations, visits were stopped and 56.4% of settings published information about the special requirements for visiting arrangements. In 32.7% of all examined units upfront approval from a physician or the head of a department for visiting a patient was required, and 29.1% published information about personal protective equipment. 32.7% of organizations recommended telephone contact with the patient, and 12.7% provided video calls.Conclusions: Web information regarding visiting patients in in-patient palliative care settings is limited. There is a need to establish detailed requirements for the visits with better access to the website for the visitors, in case of a global disease outbreak. [ABSTRACT FROM AUTHOR]

Context: Several prognostic models such as the Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), Palliative Prognostic Score (PaP) have been developed to complement clinician's prediction of survival (CPS). However, few studies with large scales have been conducted to show which prognostic tool had better performance than CPS in patients with weeks of survival.Objectives: We aimed to compare the prognostic performance of the PPS, PPI, PaP, and CPS in inpatients admitted to palliative care units (PCUs).Methods: This study was part of a multi-center prospective observational study involving patients admitted to PCUs in Japan. We computed their prognostic performance using the area under the receiver operating characteristics curve (AUROC) and calibration plots for seven, 14-, 30- and 60-day survival.Results: We included 1896 patients with a median overall survival of 19 days. The AUROC was 73% to 84% for 60-day and 30-day survival, 75% to 84% for 14-day survival, and 80% to 87% for seven-day survival. The calibration plot demonstrated satisfactory agreement between the observational and predictive probability for the four indices in all timeframes. Therefore, all four prognostic indices showed good performance. CPS and PaP consistently had significantly better performance than the PPS and PPI from one-week to two-month timeframes.Conclusion: The PPS, PPI, PaP, and CPS had relatively good performance in patients admitted to PCUs with weeks of survival. CPS and PaP had significantly better performance than the PPS and PPI. CPS may be sufficient for experienced clinicians while PPS may help to improve prognostic confidence for inexperienced clinicians. [ABSTRACT FROM AUTHOR]

Background: To address the need for short-term prognostic methods using objective measures, we developed a method to predict a 2- or 3-week prognosis using only six clinical tests (known as the WPCBAL score). However, the method has not yet been directly compared with globally accepted prognostic methods., Objectives: This study aimed to clarify the usefulness of the WPCBAL score by comparing it with other prediction methods., Setting/subjects: A prospective observational study was conducted with patients admitted to the palliative care unit of a Municipal Hospital in Japan between November 2017 and May 2021., Measurements: The primary endpoint was each prediction method's accuracy-the WPCBAL score, Glasgow Prognostic Score (GPS), Palliative Prognostic Index (PPI), Palliative Prognostic Score (PaP), Delirium-Palliative Prognostic Score (D-PaP), and Prognosis in Palliative Care Study predictor models (PiPS-A, PiPS-B)-in predicting a prognosis at 2 or 3 weeks. The secondary endpoints were sensitivity, specificity, positive and negative predictive values, area under the receiver operating characteristic curve, and each prediction method's feasibility rate., Results: In total, 181 patients were included in this study. For the 3-week prognosis, the PaP had the highest accuracy (0.746), followed by the D-PaP (0.735), WPCBAL (0.696), PPI (0.652), and GPS (0.575). For the 2-week prognosis, the PiPS-B had the highest accuracy (0.702), followed by the WPCBAL (0.696) and PiPS-A (0.641)., Conclusions: The WPCBAL score's accuracy in predicting a 2- or 3-week prognosis was comparable to that of commonly used prognostic methods, thus suggesting its usefulness as a short-term prognostic method., (© The Author(s) 2024. Published by Mary Ann Liebert, Inc.)

Background: Femoral pathological fractures (PFs) due to bone metastasis result in exacerbation of pain, gait disturbance, and reduced general condition. Surgery may be considered depending on the situation, but is not suggested often, and treatment is difficult toward the end of life. Objective: Terminal cancer patients with a femoral PF admitted to a palliative care unit (PCU) were retrospectively evaluated. Measurement: Seven cancer patients diagnosed with a femoral PF at a PCU on admission, in Japan, were examined for clinical background, physical symptoms, and psychiatric symptoms. In addition, the responses of the patients' families and medical staff were examined. This study was approved by the ethics board of our hospital. Results: A total of 28.6% of patients were hospitalized from home, and the trigger for PF could not be confirmed in 85.7% of patients. In all cases, surgery was not recommended, given the poor prognosis. Opioid drugs were used for pain in all patients, and 85.7% of patients were able to relieve their symptoms. Delirium was observed in 71.4% of cases, and treatment with antipsychotics was required in all cases. Family grief also emerged as a problem, and the staff was burdened; hence, we addressed this at the death conference. Conclusions: Even for femoral PFs in cancer patients with a limited prognosis, it is necessary to perform tests and control pain. In addition, it is important to support the mental distress of patients and their families in a short period; medical staff should be trained to support the families after the patients' death.

Refractory cancer-related pain at end-of-life (EoL) is multifaceted and may require utilizing medications with different mechanism of actions beyond opioids. We report the successful use of dexmedetomidine in a 63-year old female with recurrent breast cancer and intractable left arm pain and swelling admitted to University of California, San Diego, Health (UC San Diego Health), palliative care unit. Patient's pain and agitation continued to persist and she declined clinically despite efforts to start methadone, continuous infusion opioids, continuous infusion lidocaine and intravenous chlorpromazine by the palliative care team. On hospital day (HD) 11 patient was started on dexmedetomidine continuous infusion for refractory pain per our protocol at UC San Diego Health. The next day the patient appeared much improved in terms of pain and agitation with grimacing and moaning completely resolved. She was able to have some lucid periods and interacting with her family. With the addition of dexmedetomidine to her pain regiment, the patient was able to peacefully die 5 days later. This case report highlights the clinical utility of demedetomidine in a palliative care unit for refractory pain at EoL. [ABSTRACT FROM AUTHOR]

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decisionmaking, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life. [ABSTRACT FROM AUTHOR]

Background: Nonmedical opioid use (NMOU) has been associated with opioid overdose deaths. This pattern of misuse can be seen in those using opioids for cancer-associated pain. We present a case that highlights the complexities associated with NMOU and a patient's care at the end of life. Cases Description: A patient with a metastatic solid tumor malignancy along with co-occurring history of polysubstance abuse was admitted to an acute palliative and supportive care unit (APSCU). The patient demonstrated behaviors concerning for NMOU during her hospital stay but had increased symptom expression concerning for worsening dyspnea while in the APSCU. Unfortunately, she used home opioids, which was unknown to the team at the time along with requesting for higher doses of opioids that were being prescribed. This caused a worsening respiratory status and affected her care. Using an interdisciplinary approach, the providers managed her symptoms and discharged her safely to see her child. Conclusion: This highlights the complexities of the alleviation of suffering in those with NMOU. It is important to continue to manage NMOU at the end of life due to its effects on quality of life. A multimodal approach is recommended to identify and care for these patients. [ABSTRACT FROM AUTHOR]

The encounter between divergent institutional logics may be challenging for nurses, since they must balance different expectations in their daily institutional work. These challenges increase when new reforms are introduced. Our research question is: How do actors linked to a palliative care unit experience the consequences of the Coordination reform in their daily performance of care work? Our study is based on a qualitative study in a palliative care unit in a nursing home where we interviewed patients, their relatives, and nurses/department leaders. Our findings show that by downgrading the professional logic because of the Coordination reform, the focus is on efficiency and budget instead of proper healthcare. This is not satisfactory for any of the actors in our study. We contribute to the research on the reforming of the healthcare sector by focusing on how different actors experienced day-to-day activities in a context where different institutional logics were involved. [ABSTRACT FROM AUTHOR]

The prevalence of patients affected by end-stage diseases or advanced cancer is increasing due to an aging population and progression in medicine and public healthcare. The burden of symptoms these people suffer in the last months of life often forces them to seek aid in an emergency department. In developed countries, acute care hospital-based services are often better designed to treat acute clinical conditions than to manage the needs of patients with serious chronic diseases. Thus, the palliative care (PC) population poses very real clinical challenges to healthcare professionals who care for them in hospital settings. The authors have formulated four key questions (who, why, when, and how) to address in order to identify a model for providing the best care for these PC patients. The questions are related to: (1) defining people living with serious chronic diseases; (2) managing the challenge of unplanned hospital admission of these people; (3) identifying PC patients among people with serious chronic diseases; and (4) determining the appropriate work of caring for this inpatient PC population. Clinicians need the knowledge, tools, and services to care for these PC patients, and acute care hospitals should plan the work of caring for these inpatients. [ABSTRACT FROM AUTHOR]

Context: With global population aging, the number of older patients with cancer is increasing. However, few data are available on palliative care for these patients.Objectives: To evaluate differences in symptom prevalence and the need for medical interventions among patients of different ages in a palliative care unit.Methods: In this retrospective analysis, a consecutive sample of 1032 terminally ill patients with cancer were categorized into the following age ranges: <70, 70-79, 80-89, and ≥90 years. We evaluated symptom prevalence, the need for palliative medicines, opioid dose on the day before death, and the need for palliative sedation. Trend tests were used to examine whether the prevalence of findings increased or decreased with age.Results: As age increased, significant decreasing trends were observed in the prevalence of pain, dyspnea, fatigue, constipation, nausea, drowsiness, difficulty sleeping, anxiety, and dysuria but not in appetite loss, edema, sputum production, or delirium. As age increased, significant decreasing trends were also observed in the need for opioids, benzodiazepines, antiemetics, and anticholinergics. The median opioid doses in the <70, 70-79, 80-89, and ≥90 years age groups were 118, 72, 48, and 48 mg oral morphine equivalents/day, respectively (P < 0.0001). The need for palliative sedation showed a significant decreasing trend as age increased (P < 0.0001).Conclusion: We found age to be inversely related to symptom prevalence and medical interventions among terminally ill patients with cancer, contributing to the understanding of the experience of older patients with cancer. [ABSTRACT FROM AUTHOR]

Abstract Background Although rehabilitation is recommended for terminal cancer patients, the specific components and methods of such programs are poorly documented. No studies to date have examined the effectiveness of rehabilitation for terminal cancer patients. This study aims to evaluate the efficacy of a new intervention for rehabilitation therapists, using the Op-reha Guide (Guide to Optimal and Patient-Centred Rehabilitation Practice for Patients in Palliative Care Units [PCUs]) in rehabilitation practice. This guide consists of recommended actions and attitudes for rehabilitation therapists and aims to optimise therapists’ actions according to the patient’s needs and condition. It shares goals with terminal cancer patients to maintain their activities of daily living (ADL). Methods This study uses a multicentre, prospective, randomised controlled trial (RCT) design with two parallel groups in PCUs where specialised rehabilitation will be routinely performed for terminal cancer patients by rehabilitation therapists. Participants will be randomised (1:1) to intervention (the Op-reha Guide) and control groups (usual rehabilitation). We will then conduct an observational study in PCUs that do not perform specialised rehabilitation for terminal cancer patients; this will be considered the usual care group, and the efficacy of usual rehabilitation will be quantitatively evaluated. Inclusion criteria are hospitalisation in PCU, European Cooperative Oncology Group Performance Status of 2 or 3, and clinical estimation of life expectancy of 3 weeks or more. Patients with severe symptom burden will be excluded. We hypothesise that the Op-reha Guide will be more effective in maintaining the ADL of terminal cancer patients hospitalised in PCUs than usual rehabilitation. The primary endpoint is defined as the change in (total) modified Barthel Index from baseline to Day 22. Quality of life will be a secondary endpoint. In total, 135 patients will be recruited from 16 Japanese sites between July 2019 and December 2021. Discussion This will be the first trial to evaluate the efficacy of specialised rehabilitation for terminal cancer patients hospitalised in PCUs, and will contribute to the evidence on the efficacy of implementing rehabilitation for terminal cancer patients. Trial registration UMIN-CTR, UMIN000037298 R000042525 (date of registration 7 July 2019).

Background: Informal caregivers may experience a significant burden while caring for cancer patients. Little is known about how caregiver burden varies across different palliative cancer care settings and the factors influencing it. Objectives: We compared the severity of caregiver subjective stress burden (emotional impact) among caregivers of patients seen in the outpatient supportive care center (SCC) with those being cared for in the acute palliative care unit (PCU). Secondary aims were to compare other caregiver burden dimensions, quality of life, and any association of caregiver subjective stress burden to various patient and caregiver factors. Setting and Design: Eligible patients and their informal caregivers in the SCC or PCU at a comprehensive cancer center in the USA were approached and enrolled. The Montgomery–Borgatta Caregiver Burden Scale and the Short-form 36 were used to measure burden and quality of life. Multivariate general linear regression was employed to evaluate the effect of covariates on subjective stress burden. Results: Ninety-eight dyads in the SCC and 74 dyads in the PCU were enrolled. PCU caregivers reported worse subjective stress burden (p = 0.0029) and mental health (p = 0.0299). Multivariate analysis showed correlations between subjective stress burden and caregivers' objective burden (p = 0.0136), subjective demand burden (p ≤ 0.0001), mental health (p = 0.0074), duration of caregiving (p = 0.0680), education (p = 0.0192) and with patients' anxiety (p = 0.0003) and current/recent cancer treatment (p = 0.0579). Conclusion: PCU caregivers demonstrated worse emotional burden and mental health than those in the SCC. More research is needed to tailor interventions for various caregiver burden dimensions. NCI Clinical Trial Registration Number ID: NCI-2019-01197 [ABSTRACT FROM AUTHOR]

Objectives: Current guidelines suggest that patients with severe dementia on cholinesterase inhibitors (CHEIs) should discontinue their CHEIs by taper. This study aims to define the prevalence of patients admitted to a palliative care unit (PCU) with dementia on a CHEI and to determine whether these patients were tapered off their CHEIs according to current deprescribing guidelines. Design: This is a descriptive retrospective chart review that examined patients admitted to a PCU with dementia on a CHEI from January 2015 to June 2019. Methods: Individuals admitted to the PCU with a primary or comorbid diagnosis of dementia were identified. Their corresponding CHEI dose, frequency and discontinuation pattern were identified. Data were analyzed using descriptive statistics. Results: A total of 36 patients were admitted to the PCU with dementia on a CHEI (prevalence of 2.3%). The median length of stay was 21 days. For 31 of these patients, their CHEI was discontinued, only 9 of which had a taper. Of the 24 patients who discontinued their CHEI suddenly, 10 patients had an order to discontinue their CHEI in the last 2 days before their date of death. Conclusion: This study suggests that although patients admitted to a PCU with dementia have their CHEI discontinued, the discontinuation was done without a taper. In many cases the CHEIs were continued through the active stage of dying. Future work should explore reasons why PCU physicians are mostly late to taper CHEIs for patients admitted with dementia. [ABSTRACT FROM AUTHOR]

Background: Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors. Aim: We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries. Design: This is an international multicenter prospective cohort study. Setting/participants: Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country. Results: A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan. Conclusions: This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care. [ABSTRACT FROM AUTHOR]

Purpose: The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available. Methods: In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected. Results: Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7–51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1–53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not. Conclusions: This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary. [ABSTRACT FROM AUTHOR]

Purpose: Spiritual well-being is very important in patients undergoing palliative care. Although psychosocial factors have been suggested to be associated with spiritual well-being, the relationship between physical signs and spiritual well-being has not been fully elucidated. The aim of this study was to explore diverse factors associated with spiritual well-being among palliative care patients in Japan. Methods: This study is a secondary analysis of a multicenter prospective cohort study involving patients admitted to palliative care units in Japan. Physicians recorded all data prospectively on a structured sheet designed for the study. The spiritual well-being score was measured using the Integrated Palliative Outcome Scale after patients' death in regard to symptoms over the previous 3 days. We classified each patient into "better" score (0–1) and "worse" score (2–4) groups and examined diverse factors associated with spiritual well-being. Results: Among the 1896 patients enrolled, 1313 were evaluated. In the multivariate analysis, seven variables were significantly associated with "worse" score: worse spiritual well-being on admission (2–4) (p < 0.0001), younger age (< 80) (p = 0.0001), hyperactive delirium over 3 days before death (mild/moderate/severe) (p = 0.0001), expressed wish for hastened death (yes) (p = 0.0006), worse communication among patients and families (Support Team Assessment Schedule score 2–4) (p = 0.0008), pleural effusion (present) (p = 0.037), and marital status (unmarried) (p = 0.0408). Conclusion: Recognizing factors associated with spiritual well-being is potentially useful for identifying high-risk groups with lower spiritual well-being at the end of life. Further study is required to investigate factors associated with patient-reported spiritual well-being. [ABSTRACT FROM AUTHOR]

Background: In Switzerland, palliative care (PC) clinical training is well established at undergraduate and specialist postgraduate levels. However, postgraduate nonspecialist training curricula are less documented., Local Problem: A structured curriculum for nonspecialist rotation within internal medicine (IM) in specialized PC wards is lacking., Objective: To pilot two versions of a PC nonspecialist curriculum for IM residents in Swiss PC units., Methods: In the pilot phase, two curricula-short immersion (3-10 weeks, based on the University of Toronto's Internal-Medicine PC Rotation) and standard nonspecialist (11-18 weeks, based on the Canadian Society of Palliative Care Physician Competencies)-were assessed using a mixed-method online survey. One university and two nonuniversity sites participated. The analysis was descriptive., Results: Five residents and eight supervisors of five training rotations (July-October 2023) responded. Overall, curriculum quality and feasibility (content and time) received positive ratings across all groups, with high satisfaction concerning organization, educational design, learning support, climate, experience, and facilities. Nonuniversity sites were generally rated more positively than university sites. Qualitative feedback paralleled these findings, highlighting the curriculum's relevance and fit with learners' needs and suggesting potential simplifications and more personalized planning., Conclusions: Establishing short and standard duration curricula for a PC program is viable and well received by nonspecialist trainees. Future implementation should concentrate on personalized learning objectives and streamlining the content and structure of the competencies. Cooperation within various training settings (university and regional hospitals) as well as on an international level (e.g., Canada-Switzerland) may further improve the quality of the proposed training formats., Competing Interests: All authors declare that they have no conflicts of interest to disclose., (© Andreas Samuel Ebneter et al., 2024; Published by Mary Ann Liebert, Inc.)

Purpose: For appropriate advance care planning, functional prognostication is necessary. However, there are no studies of functional prognostication in patients with cancer. The aim of this study was to develop a functional prognostic scoring system for patients with advanced cancer. Methods: In this multicenter prospective observational study, 1896 patients were enrolled. First, Cox regression analysis and the combination of forward and backward variable selection were used to identify the best subset of predictors. Second, the prognostic score value was defined from each regression coefficient of a significant prognostic factor. The Functional Palliative Prognostic Index (FPPI) was calculated by summing the prognostic scores. Results: Patients were classified into three groups by the FPPI. For walking, the 14-day functional survival probability was > 72.8% for group A (score 0), 28.4–72.8% for group B (score 1), and < 28.4% for group C (score 2–3). For eating, the 14-day functional survival probability was > 71.8% for group A (score 0–3), 29.6–71.8% for group B (score 3.5–5.5), and < 29.6% for group C (score 6–9). For communicating, the 14-day functional survival probability was > 76.6% for group A (score 0–6.5), 22.6–76.6% for group B (score 7–10), and < 22.6% for group C (score 10.5–16). Regarding each item, group B functionally survived significantly longer than group C, and group A functionally survived significantly longer than either of the others. Conclusion: We firstly developed a functional prognostic scoring system for patients with advanced cancer. This FPPI system promises to be helpful in advance care planning. [ABSTRACT FROM AUTHOR]

Background: Metastatic breast cancer (MBC) is generally incurable, but patients can survive longer than those with other cancer types. Treatment strategies for MBC are complex, and it is difficult to establish evidence of efficacy since symptoms and patient backgrounds vary markedly. Some patients struggle to decide where to receive end-of-life care, despite palliative care intervention, and some die in unexpected places. With the aim of ascertaining the best way to intervene on behalf of patients with end-stage breast cancer, we retrospectively examined interventions provided by our palliative care team. We investigated factors influencing the decision-making processes of patients with MBC regarding end-of-life care locations and where patients actually died. Methods: Clinical records of 44 patients with MBC, all Japanese women, who received palliative care interventions at our hospital, were retrospectively investigated. We examined factors, such as age, possibly impacting decision-making processes regarding the final location and actual place of death. Results: Thirty-five (80%) patients were able to decide where to receive end-of-life care, while the others were not. For these 35 patients, desired locations were the palliative care unit (77%), home palliative care (14%), and the hospital (9%). Age and recurrence-free survival (RFS) were factors influencing patients' decision-making processes (P =.030 and.044, respectively). Of the 35 patients, 25 (71%) were able to receive end-of-life care at their desired locations. Conclusions: Young patients and those with short RFS struggled with making decisions regarding where to receive end-of-life care. Such patients might benefit from prompt introduction of advanced care planning. [ABSTRACT FROM AUTHOR]

Background: Although the risk factors for hypomagnesemia in inpatients and outpatients have been identified, these factors are yet to be determined in patients with end-stage cancer Objective: To determine the risk factors for hypomagnesemia in patients with end-stage cancer Design: Retrospective study Setting/Subjects: Patients with end-stage cancer who were hospitalized in a palliative care unit at Himeji St. Mary's Hospital, Japan, between January 2017 and June 2019 Measurements: Laboratory results of blood samples collected from patients in the palliative care unit were retrospectively examined. Medical records were assessed to identify patients with risk factors for hypomagnesemia, as elucidated by earlier studies involving inpatients and outpatients, and to evaluate their disease-related physical status. Logistic regression analysis was used to analyze the relationship between the risk factors and the patients' physical status Results: During the study period, 570 patients with end-stage cancer were hospitalized in our palliative care unit. Serum magnesium levels were measured in 432 patients, and hypomagnesemia was observed in 82 (18.98%) of those. Predictor variables of a significantly higher incidence of hypomagnesemia onset included the female sex and previous use of platinum-based antitumor drugs. In contrast, predictor variables of a significantly lower incidence of hypomagnesemia onset included the use of magnesium oxide laxatives Conclusions: Female sex and previous use of platinum-based antitumor drugs were identified as risk factors for hypomagnesemia in patients with end-stage cancer [ABSTRACT FROM AUTHOR]

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Background: There is no established method to objectively predict short-term prognosis. Recently, we proposed objective, short-term, prognostic predictive methods that are combinations of laboratory test items: WPCBAL score, derived from six values (white blood cell, platelet, C-reactive protein, blood urea nitrogen, aspartate aminotransferase, and lactate dehydrogenase). However, that study was conducted in an acute-phase hospital to identify the test items useful for prognostic prediction; thus, whether WPCBAL score could be applied to terminal cancer patients in a palliative care unit was unverified. Objective: To verify the usefulness of WPCBAL score for terminal cancer patients. Design: A retrospective study. Setting/Subjects: Patients admitted to the palliative care unit of Ashiya Municipal Hospital (N = 128) in Japan in 2016. Measurements: The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve (AUROC) were compared between WPCBAL score and the Glasgow prognostic score (GPS). Results: For predicting three-week prognosis, WPCBAL score showed higher AUROC compared with GPS (0.7540 and 0.6573, respectively). WPCBAL score predicting two-week prognosis showed greater AUROC than GPS predicting three-week prognosis (0.7491 and 0.6573, respectively). Conclusion: WPCBAL score was verified to objectively predict the two- or three-week prognosis for terminal cancer patients in a palliative care unit. WPCBAL score may be a new option for prognostic prediction for terminal cancer patients. [ABSTRACT FROM AUTHOR]

Context: Many older adults discharged from an inpatient stay require postacute facility placement, which can be a barrier to hospice enrollment since the Medicare hospice benefit does not cover facility costs for patients under routine hospice care. Objectives: To evaluate the extent to which need for postdischarge facility care was a barrier to hospice enrollment for older patients with short life expectancy discharged from a palliative care unit. Methods: Retrospective cohort using a prospectively collected database of patients 65 and older with a life expectancy of <6 months admitted to a palliative care unit in an urban, academic medical center and discharged alive from 2012 to 2017. Primary outcome was hospice enrollment at hospital discharge. Exposure of interest was need for facility placement at discharge. Results: Of 817 included patients, 649 (79%) were discharged with hospice. Patients discharged home had a significantly higher rate of hospice enrollment than patients discharged to a facility—92% versus 71% (P < .0001). On multivariate logistic regression analysis, discharge to home versus facility remained a strong predictor of hospice enrollment, with an odds ratio for hospice enrollment of 6.04 (95% confidence interval: 3.73-9.79). Conclusion: Need for postdischarge facility placement represents a barrier for hospice enrollment among older patients who are otherwise hospice appropriate. The structure of the hospice benefit may require modification so that these hospice appropriate patients can utilize the benefit. [ABSTRACT FROM AUTHOR]

Background: There is few literature on the difficulties and different meanings of gastrostomy tubes (GST) for parents of children with palliative needs, and what specific palliative care teams contribute to this process. Aim: To explore the process of information in the decision of performing a gastrostomy and the meanings that parents of children with palliative needs build around them. Design: Semi-structured interviews which were transcribed and analysed using Grounded Theory. Setting/participants: Parents and caretakers of children admitted in Paediatric Palliative Care Unit of Madrid Autonomous Community (Spain) whose children bore a gastrostomy device. Results: Two core categories arise ('Fight' and 'The child as a life-meaning generator'). In all the cases, the child supplied the meaning to go on, and the Palliative Care Unit (CPU) helped in the daily care of the child and solving problems derived from the handling of the GT. Conclusions: It is necessary to improve the process of giving bad news and to introduce models of health care that focus on parents and child as the center of palliative care. It is also necessary to develop educational programs that enable continuity of care at home for children with palliative needs. [ABSTRACT FROM AUTHOR]