Decision making at the end of life—cancer patients’ and their caregivers’ views on artificial nutrition and hydration

Malnutrition management and the application of medical nutrition therapy in hospitalized patients at the end of life

OBJECTIVES

(1) To determine the prevalence of malnutrition risk in hospitalized patients at the end of life (EOL), (2) to evaluate which nutritional interventions are administered in hospitalized end-of-life patients with malnutrition risk and (3) to assess the association of end-of-life care and the administration of medical nutrition therapy in patients with malnutrition risk.

DESIGN

Cross-sectional multi-center study SETTING: Hospital PARTICIPANTS: Hospitalized adult patients MEASUREMENTS: Based on the valid and reliable questionnaire of the Nursing Quality Measurement 2.0 (LPZ), the parameters of demographic data, medical diagnoses, end-of-life phase, care dependency, malnutrition risk according to the Malnutrition Universal Screening Tool (MUST) and nutritional interventions conducted in patients at risk of malnutrition were assessed. Descriptive statistics and statistical tests were conducted. Logistic regression models were established to identify odds ratios (OR) and confidence intervals (CI) for the association of end-of-life care and the provision of medical nutrition therapy. This was done separately for oral nutritional supplements (ONS), enteral nutrition and parenteral nutrition as the respective dependent variables.

RESULTS

Of all 12,947 participants, 706 (5.5%) were in an end-of-life phase. The prevalence of malnutrition risk in end-of-life patients was 41.1% compared to 24.7% in other patients (p < 0.001). End-of-life patients with malnutrition risk received more nutritional interventions than other patients with malnutrition risk. The regression models showed that being at the end of life (CI 1.30, 2.63; p < 0.001), being treated by a dietitian (OR 6.02; CI 4.86, 7.45; p < 0.001), suffering from dementia (OR 1.85; CI 1.10, 3.12; p = 0.02) or cancer (OR 1.56; CI 1.25, 1.96; p < 0.001) increased the chance of receiving oral nutritional supplements. For receiving parenteral nutrition, being at the end of life (OR 1.68; CI 1.04, 2.71; p = 0.04), being treated by a dietitian (OR 5.80; CI 4.07, 8.25; p < 0.001), surgery within the previous two weeks (OR 1.58; CI 1.09, 2.30; p = 0.02), younger age (OR 0.99; CI 0.98, 1.00; p = 0.04), care dependency (OR 0.97; CI 0.96, 0.98; p < 0.001), suffering from a disease of the digestive system (OR 2.92; CI 2.07, 4.11; p < 0.001) or cancer (OR 2.44; CI 1.71, 3.49; p < 0.001) were independent predictors. Being at the end of life did not influence the application of enteral nutrition.

CONCLUSION

This study showed that nutritional interventions are often applied in end-of-life patients admitted to general hospitals. Being at the end of life was positively associated with the application of oral nutritional supplementation and parenteral nutrition. This data does not allow a conclusion about the appropriateness of using medical nutrition therapy in this study sample. Judging the appropriateness of medical nutrition therapy at the end of life is challenging because of the high variability of prognostication as well as the wishes and needs of the specific patients and their relatives that influences the appraisal of adequate interventions. Every decision about nutrition and hydration in end-of-life patients should be a shared decision and be based on advanced care planning principles.

Urban people's preferences for life-sustaining treatment or artificial nutrition and hydration in advance decisions

BACKGROUND

The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and withdrawal of life-sustaining treatment (LST) or artificial nutrition and hydration (ANH) in situations like irreversible coma, vegetative state, severe dementia, or unbearable pain. This study aims to investigate preferences for LST or ANH across various clinical conditions, variations in participant preferences, and factors influencing these preferences among urban residents.

METHODS

Employing a survey of legally structured AD documents and convenience sampling for data collection, individuals were enlisted from Taipei City Hospital, serving as the primary trial and demonstration facility for ACP in Taiwan since the commencement of the PRAA in its inaugural year. The study examined ADs and ACP consultation records, documenting gender, age, welfare entitlement, disease conditions, family caregiving experience, location of ACP consultation, participation of second-degree relatives, and the intention to participate in ACP.

RESULTS

Data from 2337 participants were extracted from electronic records. There was high consistency in the willingness to refuse LST and ANH, with significant differences noted between terminal diseases and extremely severe dementia. Additionally, ANH was widely accepted as a time-limited treatment, and there was a prevalent trend of authorizing a health care agent (HCA) to make decisions on behalf of participants. Gender differences were observed, with females more inclined to decline LST and ANH, while males tended towards accepting full or time-limited treatment. Age also played a role, with younger participants more open to treatment and authorizing HCA, and older participants more prone to refusal.

CONCLUSION

Diverse preferences in LST and ANH were shaped by the public's current understanding of different clinical states, gender, age, and cultural factors. Our study reveals nuanced end-of-life preferences, evolving ADs, and socio-demographic influences. Further research could explore evolving preferences over time and healthcare professionals' perspectives on LST and ANH decisions for neurological patients..

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted hydration in patients with advanced cancer

PURPOSE

The provision of clinically assisted hydration (CAH) in patients with advanced cancer is controversial, and there is a paucity of specific guidance and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a sub-group to develop evidence-based guidance on the use of CAH in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials, respectively.

RESULTS

Due to the paucity of evidence, the sub-group was not able to develop a prescribed guideline, but was able to generate a number of "expert opinion statements": these statements relate to assessment of patients, indications for CAH, contraindications for CAH, procedures for initiating CAH, and reassessment of patients.

CONCLUSIONS

This guidance provides a framework for the use of CAH in advanced cancer, although every patient requires individualised management.

Decision-making in palliative care: patient and family caregiver concordance and discordance-systematic review and narrative synthesis

BACKGROUND

Decision-making in palliative care usually involves both patients and family caregivers. However, how concordance and discordance in decision-making manifest and function between patients and family caregivers in palliative care is not well understood.

OBJECTIVES

To identify key factors and/or processes which underpin concordance and/or discordance between patients and family caregivers with respect to their preferences for and decisions about palliative care; and ascertain how patients and family caregivers manage discordance in decision-making in palliative care.

METHODS

A systematic review and narrative synthesis of original studies published in full between January 2000 and June 2021 was conducted using the following databases: Embase; Medline; CINAHL; AMED; Web of Science; PsycINFO; PsycARTICLES; and Social Sciences Full Text.

RESULTS

After full-text review, 39 studies were included in the synthesis. Studies focused primarily on end-of-life care and on patient and family caregiver preferences for patient care. We found that discordance between patients and family caregivers in palliative care can manifest in relational conflict and can result from a lack of awareness of and communication about each other's preferences for care. Patients' advancing illness and impending death together with open dialogue about future care including advance care planning can foster consensus between patients and family caregivers.

CONCLUSIONS

Patients and family caregivers in palliative care can accommodate each other's preferences for care. Further research is needed to fully understand how patients and family caregivers move towards consensus in the context of advancing illness.

The responsibility to quench thirst by providing drinks when a relative is dying spouses' experience in specialist palliative home care

BACKGROUND

Thirst and dry mouth are common symptoms in terminally ill patients. It is known that family members usually request drips for their dying relative. Few studies have focused on thirst in terminally ill patients and their spouses' experience of this, leading to a knowledge gap in this area.

AIM

The aim of this study was to explore spouses' experiences of observing and managing thirst in a dying relative admitted to specialist palliative home care.

METHODS

A qualitative interview study with an inductive approach was conducted. Eighteen spouses caring for their husband or wife admitted to specialist palliative home care in different hospitals in Sweden were interviewed. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis.

RESULTS

Three main themes emerged regarding spouses' experiences of patients' thirst: Knowledge and views of thirst; Control of fluid intake provides vital information; and Taking charge of their drinking is a life and death responsibility.

CONCLUSIONS

Spouses experience a responsibility to serve the dying person with fluids so that they will not get thirsty. It is so obvious and commonplace to them. To be able to fulfil this responsibility, they need to keep track of the patient's fluid intake and know what quenches thirst. There is a need for research in this area to assist carers and patients in identifying which drinks best quench the patient's thirst. Interventions are also needed to help provide/make available knowledge on suitable thirst-quenching drinks.

The experiences of family members witnessing the diminishing drinking of a dying relative in hospital: A narrative inquiry

BACKGROUND

The optimal management of diminishing drinking at the end of life is contentious. Clinicians and family members may understand the phenomenon differently and hold divergent priorities regarding care. Family members can be distressed by diminishing drinking and its management, particularly when in a hospital environment.

AIM

To explore the experiences of family members when witnessing the diminishing drinking of a dying relative.

DESIGN

A narrative inquiry methodology, derived from pragmatism.

SETTING AND PARTICIPANTS

Thirteen recently bereaved family members were recruited through the bereavement services of three UK hospitals. Inclusion criteria included having an adult relative who died in hospital of any diagnosis more than 48 hours from admission and who had had noticeable diminishing drinking.

FINDINGS

Participants experienced diminishing drinking as an unfolding process that was part of overall decline. They all believed it to be detrimental. Three groups of responses were identified: promoting, accepting and ameliorating. Supportive measures included offering equipment to support drinking, staff being present and communicating about expectations and care management aims.

CONCLUSIONS

There is potential to improve family members' experiences through re-conceptualisation of diminishing drinking aligned to their experiences, supporting family members by listening to their experiences with insight and strengthening their agency within the management of their relatives with diminishing drinking.

Clinical effects of hydration, supplementary vitamins, and trace elements during end-of-life care for cancer patients

INTRODUCTION

current data regarding the decision on rehydration of patients with terminal-stage cancer remain controversial.

OBJECTIVE

the present study was to evaluate the effect of intravenous hydration and supplementary vitamins and trace elements on clinical symptoms and biochemical parameters in palliative cancer patients.

METHODS

a randomized clinical trial including 72 palliative cancer patients aged 18 years and older was performed at the National Cancer Institute in Mexico. Patients were divided into two groups: intervention and control, both receiving intravenous saline solution weekly for 4 weeks, but the former was also supplemented with vitamins and trace elements. Symptoms were assessed at baseline and 4 weeks after with the Edmonton Symptom Assessment Scale. Same measurements applied to biochemical parameters.

RESULTS

the mean age of the patients was 58.75 years. The most frequent cancer diagnoses were gastrointestinal (32 %). In the between-groups analysis significant improvements were found for the intervention group in anorexia (p = 0.024), pain (p = 0.030), chloride (p = 0.043), phosphorus (p = 0.001), potassium (p = 0.006), and total proteins (< 0.0001).

CONCLUSION

we highlight the improvement in the control of most symptoms and some biochemical parameters in the intervention group receiving vitamins and oligoelements along with intravenous hydration. Further studies are needed.

Acceptance of Caregiver-Patient Support to Latinx Coping with Advanced Cancer (CASA) Intervention: A Caregiver Case Study

Latinos frequently assume caregiver roles when the need arises in their social nucleus. Because of their active role, caregivers are heavily involved in their family member's cancer trajectory. Therefore, there is a need for culturally adapted interventions that integrate the caregiver and cancer patient. The objective is to present a case study of a former caregiver's experience and acceptance of the cultural adaptation of Caregiver-Patient Support to Latinx Coping with Advanced Cancer (CASA) intervention. We conducted a case study with a male caregiver between the ages of 20 and 30. A male caregiver expressed his experience and acceptance of a psychosocial intervention. He conveyed moderate to high acceptance of intervention components through anecdotes and opinions based on his experiences as a caregiver for multiple family members. Finally, he reported distress, but he presented little to no symptoms of caregiver burden, depression, anxiety, and hopelessness. It is crucial to culturally adapt interventions that integrate caregivers when they play a big part in their loved one's cancer journey. Integrating their perspective when adapting an intervention may assist in providing essential information that will benefit the patient and caregiver.

Parenteral Nutrition in Pediatric Patients with Neurodisability: Current Perspectives

Pediatric neurodisability describes functional limitations in children with varied severity and complexity often attributed to brain or neuromuscular abnormalities. The life expectancy of children with neurodisability is improving, but many will require significant medical support. The gastrointestinal tract is usually affected in children with neurodisability and can lead to a wide range of symptoms. In gastrointestinal (GI) dystonia, a newly coined term, feeding will trigger a distressing dystonia and symptoms can improve with cessation of feed. Parenteral nutrition (PN) is often viewed as a viable option in severe GI dystonia or when enteral feeding does not support sufficient nutrition. The use of PN in children with severe neurodisability is complex. It involves an intricate interplay between medical, psychological and ethical factors. In the absence of a universally agreed guidance on the use of PN in this cohort, paediatricians should maintain the individual need of the child at the centre of the decision-making process and work closely with families and other healthcare professionals before initiating or withholding PN in children with severe neurodisability. In this article, we discuss the complex and multifaceted approach to the use of PN in children with severe neurodisability and aimed to explore the medical, psychological and ethical aspect dilemmas facing clinicians looking after children with declining gut function who may require PN support.

Clinically assisted hydration in patients in the last days of life ('CHELsea II' trial): a cluster randomised trial

INTRODUCTION

Provision of clinically assisted hydration (CAH) at the end of life is one of the most contentious issues in medicine. The aim of the 'CHELsea II' trial is to evaluate CAH in patients in the last days of life. The objectives are to assess the effect of CAH on delirium, audible upper airway secretions, pain and other symptoms, and overall survival, as well as the tolerability of CAH, and the health economic impact.

METHODS AND ANALYSIS

The study is a cluster randomised trial, involving 80 sites/clusters (mainly hospices) and 1600 patients. Sites will be randomised to an intervention, and this will become the standard of care during the trial. Intervention 'A' involves continuance of drinking (if appropriate), mouth care and usual end-of-life care. Intervention 'B' involves continuance of drinking, mouth care, usual end-of-life care and CAH, that is, parenteral fluids. The fluid may be given intravenously or subcutaneously, the type will be dextrose saline (4% dextrose, 0.18% sodium chloride) and the volume will be dependent on weight.Participants will be assessed every 4 hours by the clinical team. The primary endpoint is the proportion of participants who develop delirium determined using the Nursing Delirium Screening Scale (using a cut-off score of ≥2). A mixed-effects logistic regression will be used to assess the difference in the odds of developing delirium between the interventions.

ETHICS AND DISSEMINATION

Ethical committee approval has been granted by the Brighton and Sussex Research Ethics Committee (REC) (main REC for the UK: reference-IRAS 313640), and by the Scotland A REC (REC for adults with incapacity in Scotland: reference-22/SS/0053-IRAS-317637). The consent process follows the Mental Capacity Act: if the patient has capacity, then consent will be sought in the normal way; if the patient does not have capacity, then a personal/nominated consultee will be approached for advice about the patient entering the study. The consent process is slightly different in Scotland.The results of the trial will be published in general medical/palliative care journals, and presented at general medical/palliative care conferences.

TRIAL REGISTRATION NUMBER

ISRCTN65858561.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

PURPOSE

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a "category of guideline" based on the level of evidence (i.e. "recommendation", "suggestion", or "no guideline possible").

RESULTS

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

CONCLUSIONS

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

C-reactive protein and white blood cell count are adverse prognostic markers for patients with advanced cancer on parenteral nutrition in a palliative care unit setting: A retrospective cohort study

BACKGROUND

Parenteral nutrition is controversial in patients with advanced cancer. Nevertheless, this treatment is common practice near the end of life.

AIM

We aimed to identify factors which were associated with the outcome of patients on parenteral nutrition at an academic tertiary palliative care unit.

DESIGN

In this retrospective cohort study patients were assigned to two groups according to parenteral nutrition treatment. Inferential statistics were used to assess whether the dynamics of laboratory variables over 2 weeks of parenteral nutrition were associated with survival.

SETTING/PARTICIPANTS

Patients admitted to the Department of Palliative Medicine at the Medical University of Vienna between 2016 and 2018 were included in this study.

RESULTS

Of 443 patients, 113 patients received parenteral nutrition. Patients had a lower body mass index, lower levels of bilirubin, γ-glutamyltransferase, alkaline phosphatase, and were of younger age compared to patients which did not receive parenteral nutrition. No difference in survival as measured from admission to death was found when comparing the two groups. Levels for γ-glutamyltransferase, alkaline phosphatase, and C-reactive protein significantly increased during 2 weeks of parenteral nutrition. Among patients with parenteral nutrition, an increase in C-reactive protein or white blood cell count levels was associated with lower survival.

CONCLUSION

Patients who responded with an increase of C-reactive protein or white blood cell count during 2 weeks after reinitiation or start of parenteral nutrition had a worse survival. Our findings might support clinicians and patients in their decision to forgo parenteral nutrition in a palliative care setting.

Parenteral Nutrition in Advanced Cancer: The Healthcare Providers' Perspective

INTRODUCTION

The evidence base for parenteral nutrition (PN) in advanced cancer patients is limited. We studied healthcare providers' (HCPs') experiences with PN in cancer patients, focusing on perceived treatment benefits and challenges.

METHODS

An 18-item online survey was emailed to HCPs attending one of three regional palliative care seminars held within a 6-month period. The survey included single-response items, multiple-response items, and free text boxes concerning PN. Descriptive statistics and qualitative thematic content analysis were applied.

RESULTS

One hundred and two seminar participants completed the survey. Ninety-three percent were female, 86% were nurses/oncological nurses, and 80% worked in primary care. Respondents reported a well-functioning collaboration across levels of care. They perceived that PN may increase the patients' level of energy, improve the general condition, and reduce eating-related distress. On the downside, HCPs observed burdensome side effects, that the treatment was resource-demanding, and that decisions on PN withdrawal were difficult.

CONCLUSION

The study results are based on the perspectives of more than 100 HCPs with comprehensive clinical experience with PN. Their knowledge represents an important experience base for improvement of healthcare services and advanced care planning.

The experiences, perceptions, and support needs among family caregivers of patients with advanced cancer and eating problems: An integrative review

BACKGROUND

Advanced cancer patients often present with numerous eating problems, posing a significant challenge for family caregivers during the provision of nutritional care.

AIM

To systematically identify and synthesize empirical literature on the experiences, perceptions, and support needs of family caregivers of patients with advanced cancer and eating problems to ascertain directions for future research.

DESIGN

Integrative review guided by Whittemore and Knafl's methodological framework.

DATA SOURCES

Five electronic databases were searched from their inception to April 2021. Studies were eligible if they examined family caregivers' perspectives and experiences when caring for their relatives with advanced cancer and eating problems and were primary quantitative, qualitative, and mixed-methods studies published in English-language peer-reviewed journals. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies.

RESULTS

Twenty-seven papers from 21 studies met the eligibility criteria and were included in this review. The included papers were mostly qualitative studies and were of moderate to high methodological quality. Three themes were identified: (a) multiple negative effects of advanced cancer patients' eating problems; (b) coping responses in managing advanced cancer patients' eating problems; and (c) unmet support needs in the provision of nutritional care.

CONCLUSIONS

Research on the studied topic was descriptive and predominantly qualitative in nature. Quantitative research examining the impact of caregiving experiences in relation to food and eating in the context of advanced cancer patients is the first important step moving this research area forward.

Difficulties in Addressing Artificial Hydration and Nutrition Therapy for Terminal Cancer Patients: What to do if Patients/Families' Wishes Differ From the Medically Appropriate Treatment Plans?

PURPOSE

Artificial hydration and nutrition therapy (AHNT) initiated by patients/families sometimes differs from medically appropriate treatment plans. We aimed to identify the causes of these differences and examine the ensuing responses and outcomes.

METHODS

Of 133 adult cancer patients receiving end-of-life care in the last 2 years, these discrepancies occurred in 41 patients. We retrospectively examined the following issues: (1) The reason why these discrepancies occurred. (2) Based on the causes identified in (1), the following actions were taken: 1) If the consent to change to medically appropriate AHNT was obtained, physical findings using Japan Palliative Oncology Study (JPOS) group and Edmonton Symptom Assessment System (ESAS) were compared before and 1 week after the intervention. 2) If consent was not obtained, time-limited trial (TLT) was conducted, and these results were compared. (3) The communication between patients/families and medical professionals was compared using Support Team Assessment Schedule.

RESULTS

(1) Causes: a) the lack of understanding of the disease condition in 26 cases and b) faulty expectation of AHNT in 15 cases. (2) In 30 cases of 1) (20 of a) and 10 of b)) and 11 of 2) in which TLT was performed, JPOS and ESAS improved significantly. (3) The communication above was improved significantly in 1) and 2) (P = .0027 and .0039, respectively).

CONCLUSION

Providing medically appropriate AHNT with the consent of patients/families is expected to not only alleviate distressing symptoms but also improve the communication between patients/families and medical professionals, as well as improve the quality of palliative care.

Decision Making of Artificial Nutrition and Hydration for Cancer Patients at Terminal Stage-A Systematic Review of the Views From Patients, Families, and Healthcare Professionals

BACKGROUND

Decision making on nutrition and hydration for cancer patients during terminal stage cause critical impacts toward patient's comfort and living quality. The management of nutrition is the main dilemma that arises in these final situations and has been the subject of intense debate over the last few decades.

AIM

To find the views of patients, families, and healthcare professionals related to how decisions are made when cancer patients are at terminal stage.

DESIGN

This systematic review used PRISMA strategy to search and used Critical Appraisal Skills Programme checklist to evaluate the papers.

DATA SOURCES

All English papers through August 2020 that contained the view of the decision making at artificial nutrition and hydration with cancer patients, families, and healthcare professionals at terminal stage were included. Selected studies were independently reviewed, and data collaboratively synthesized into core themes.

RESULTS

Most of the terminal stage cancer patients and their families initially started the decision-making process when facing the reduction of oral intake. There are two primary considerations of patients and families, one is for prolonging patients life, and the other is to maintain their life quality. The voices of patients were influential, but not determinative; families usually had influence, but seldom make the final recommendation by themselves; healthcare professionals frequently face the dilemma about their decision.

CONCLUSION

The decision of nutritional support was dynamic; the interaction between patients and families frequently be hesitated to protect the rights of life, unnecessarily prolonging lifetime. Therefore, a better understanding of the views on nutritional support and processing the clinical guideline of decision making for healthcare professional is necessary.

Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams

Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke.

Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated.

Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness.

Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.

Oncology and Palliative Care Nurses' Knowledge and Attitudes Toward Artificial Nutrition and Hydration for Patients at End of Life in Italy: A Cross-sectional Survey

BACKGROUND

Nutrition is a basic patients' need and an important component of nursing. End-of-life cancer patients can experience difficulties in eating and drinking, sometimes requiring artificial nutrition and hydration (ANH). Nurses' knowledge and attitudes greatly influence nursing care. Nurses may lack knowledge of ANH. To date, no study has explored the knowledge and attitudes of oncology and palliative care nurses toward end-of-life ANH.

OBJECTIVE

To describe oncology and palliative care nurses' knowledge of and attitudes toward ANH.

METHODS

A multicenter cross-sectional study was conducted in 7 regions of Italy using the Italian version of the Questionnaire on Knowledge and Attitudes in Providing ANH for Terminal Cancer Patients. Attitudes were divided into benefits and burdens of providing ANH. Data were analyzed by descriptive statistics.

RESULTS

High percentages of oncology and palliative care nurses showed reasonable knowledge about ANH. More disagreement was evidenced about benefits and burdens of ANH, and lower importance was given to them.

CONCLUSIONS

Some misconceptions and a low level of awareness exist among some nurses about ANH. More nursing studies should be conducted and extended to different care settings. Moreover, guidelines should be reinforced with a nursing perspective to better define nurses' role in the decision-making process on ANH.

IMPLICATIONS FOR PRACTICE

This exploration of nurses' knowledge of and attitudes toward ANH in end-of-life cancer patients can contribute to an understanding of how nurses can be involved in better meeting cancer patients' nutritional needs at the end of life.

Nurses' perceived knowledge and benefits of artificial nutrition and hydration for patients nearing death: A survey among Jordanian nurses

OBJECTIVE

Existing research highlights the importance of nurses' knowledge and attitudes towards the provision of artificial nutrition and hydration (ANH) for patients with advanced cancer; however, the perspectives of Arabic and Islamic nurses have not yet been investigated. Therefore, we aimed to examine Jordanian nurses' knowledge, attitudes and perceived benefits in providing ANH for patients with advanced cancer.

METHOD

A descriptive cross-sectional design was employed.

RESULTS

Participants comprised 183 nurses (93.5% response rate). Around 80% received no training on ANH. Nurses had poor knowledge regarding ANH, with a mean score of 5.12 (SD=2.27) out of 15. Overall, nurses had positive attitudes towards ANH care (M = 3.09, SD = 0.29); however, the subscale analysis showed that nurses held inconspicuous beliefs about ANH benefits (M = 2.67, SD = 0.71) and strongly believed that ANH places a high burden on patients (M = 3.50, SD = 0.69). Nurses from government hospitals showed significantly higher ANH knowledge, as well as positive beliefs regarding ANH benefits, compared to less educated nurses.

CONCLUSION

Jordanian nurses have limited knowledge of ANH. Their positive attitude regarding ANH for terminally ill patients could be driven by cultural norms and beliefs, rather than education. Introducing ANH in nursing curricula and in-hospital services could have a positive impact on nurses' knowledge.

What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis

Background

Clinically assisted hydration (CAH) can be provided in the last days of life as drinking declines. The impact of this practice on quality of life or survival in the last days of life is unclear. Practice varies worldwide concerning this emotive issue.

Method

Systematic literature review and narrative synthesis of studies evaluating the impact of, or attitudes toward, CAH in the last days of life. Databases were searched up to December 2019. Studies were included if the majority of participants were in the last 7 days of life, and were evaluated using Gough’s 'Weight of Evidence' framework. Review protocol registered with PROSPERO, registration number CRD42019125837.

Results

Fifteen studies were included in the synthesis. None were judged to be both of high quality and relevance. No evidence was found that the provision of CAH has an impact on symptoms or survival. Patient and family carer attitudes toward assisted hydration were diverse.

Conclusion

There is currently insufficient evidence to draw firm conclusions on the impact of CAH in the last days of life. Future research needs to focus on patients specifically in the last days of life, include those with non-malignant diagnoses, and evaluate best ways to communicate effectively about this complex topic with patients and their families.

Beliefs and Perceptions About Parenteral Nutrition and Hydration by Family Members of Patients With Advanced Cancer Admitted to Palliative Care Units: A Nationwide Survey of Bereaved Family Members in Japan

CONTEXT

There has been a growing consensus that parenteral nutrition and hydration is to be forgone in terminally ill patients with cancer. However, it remains unclear what the beliefs and perceptions of parenteral nutrition and hydration by the family members are.

OBJECTIVES

To clarify their beliefs and perceptions and examine the relationships between the factors of family members, their beliefs and perceptions, and their overall satisfaction with the care the patient received at the place of death.

METHODS

This study was performed as a part of the cross-sectional anonymous nationwide survey of the bereaved family members of patients with cancer in Japan.

RESULTS

In total, 1001 questionnaires were sent, and 610 questionnaires were returned. Among these, 499 were analyzed. Regarding the prevalence of beliefs and perceptions about parenteral nutrition and hydration, when a patient cannot eat enough, parenteral hydration is needed was the highest (87.7%), followed by the opinions of medical staff are important in the issue of parenteral nutrition and hydration, parenteral hydration serves as a substitute for oral hydration, and if I were a patient and could not eat enough, parenteral hydration would be needed (85.1%, 81.0%, and 80.0%, respectively). We extracted two concepts as follows: belief that parenteral nutrition and hydration are beneficial and perceived need for parenteral nutrition and hydration. They were not identified as independent determinants of overall care satisfaction.

CONCLUSION

This study showed that beliefs and perceptions about parenteral nutrition and hydration were important in the family members in palliative care.

Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study

BACKGROUND

Studies on forgoing treatment often ignore treatments that are continued until death.

OBJECTIVE

To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics.

DESIGN

National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient's end of life and demographics on the physician.

PARTICIPANTS

A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051).

MAIN MEASURES

Any of nine specific treatments was continued until death, withdrawn, or withheld.

KEY RESULTS

In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70-94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals.

CONCLUSIONS

Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.

Use of artificial nutrition near the end of life: Results from a French national population-based study of hospitalized cancer patients

Background

The use of artificial nutrition, defined as a medical treatment that allows a non‐oral mechanical feeding, for cancer patients with limited life expectancy is deemed nonbeneficial. High‐quality evidence about the use of artificial nutrition near the end of life is lacking. This study aimed (a) to quantify the use of artificial nutrition near the end‐of‐life, and (b) to identify the factors associated with the use of artificial nutrition.

Methods

This was a retrospective cohort study of decedents based on data from the French national hospital database. The study population included adult cancer patients who died in hospitals in France between 2013 and 2016 and defined to be in a palliative condition. Use of artificial nutrition during the last 7 days before death was the primary endpoint.

Results

A total of 398 822 patients were included. The median duration of the last hospital stay was 10 (interquartile range, 4‐21) days. The artificial nutrition was used for 11 723 (2.9%) during the last 7 days before death. Being a man, younger, having digestive cancers, metastasis, comorbidities, malnutrition, absence of dementia, and palliative care use were the main factors associated to the use of artificial nutrition.

Conclusion

This study indicates that the use of artificial nutrition near the end of life is in keeping with current clinical guidelines. The identification of factors associated with the use of artificial nutrition, such as cancer localization, presence of comorbidities or specific symptoms, may help to better manage its use.

The experiences of family members witnessing the diminishing drinking of a dying relative: An adapted meta-narrative literature review

BACKGROUND

Addressing the concerns of family members is an important aspect of palliative and end-of-life care. One aspect that commonly causes family caregivers concern is the decline of patients' oral fluid intake in the last few days of life.

AIM

To map the narratives in which family members' experiences of witnessing the diminishing drinking of a dying relative have been researched, review the findings within each narrative and consider directions for future research.

DESIGN

An adapted meta-narrative review approach.

DATA SOURCES

The Cumulative Index of Nursing and Applied Health Literature, Medline, PsycINFO, Psycharticles and Scopus databases were searched for relevant research published between January 1982 and December 2017. Quality was assessed using the Quality Assessment and Review Instrument.

RESULTS

A total of 22 papers met the inclusion criteria. No study focused specifically on the experiences of family members when witnessing the diminishing drinking of dying relatives. However, research about diminishing drinking was identified within studies broadly focusing on cancer cachexia, clinical decision-making about hydration and/or nutrition and support in a hospice context. The research indicates that family members' experiences of diminishing drinking vary with their views about the significance of drinking, dying well and their expectations of themselves and healthcare professionals.

CONCLUSION

While some understanding of the topic can be inferred from research in related areas, there is a paucity of information specifically about family members' experiences when witnessing the diminishing drinking of a dying relative.

Do medical oncology patients and their support persons agree about end-of-life issues?

BACKGROUND

The perceptions of those called on to make decisions on behalf of patients who lack capacity at the end of life must accurately reflect patient preferences.

AIMS

To establish the extent to which the views of medical oncology outpatients are understood by their support persons, specifically with regards to (i) preferred type and location of end-of-life care, (ii) preferred level of involvement in end-of-life decision-making and (iii) whether the patient has completed an advance care plan or appointed an enduring guardian.

METHODS

Adults with a confirmed cancer diagnosis and their nominated support persons were approached between September 2015 and January 2016 in the waiting room of an Australian tertiary referral clinic. Consenting participants completed a pen-and-paper survey. Nominated support persons answered the same questions from the patient's perspective.

RESULTS

In total, 208 participants (39% of eligible dyads) participated. Observed agreement across the five outcomes ranged from 54% to 84%. Kappa values for concordance between patient-support person responses were fair to moderate (0.24-0.47) for enduring guardian, decision-making, advance care plan and care location outcomes. A slight level of concordance (k = 0.15; 95% confidence interval: -0.02, 0.32) was found for the type of care outcome.

CONCLUSION

Relying on support persons' views does not guarantee that patients' actual preferences will be followed. Strategies that make patient preferences known to healthcare providers and support persons while they still have the capacity to do so is a critical next step in improving quality cancer care.

Deaths after feeding-tube withdrawal from patients in vegetative and minimally conscious states: A qualitative study of family experience

BACKGROUND

Families of patients in vegetative or minimally conscious states are often horrified by the suggestion of withdrawing a feeding tube, even when they believe that their relative would not have wanted to be maintained in their current condition. Very little is known about what it is like to witness such a death.

AIM

To understand these families' experience of their relatives' deaths.

DESIGN

Qualitative study using in-depth narrative interviews analyzed inductively with thematic analysis.

PARTICIPANTS

A total of 21 people (from 12 families) whose vegetative or minimally conscious relative died following court-authorized withdrawal of artificial nutrition and hydration. All had supported treatment withdrawal.

FINDINGS

Interviewees were usually anxious in advance about the nature of the death and had sometimes confronted resistance from, and been provided with misinformation by, healthcare staff in long-term care settings. However, they overwhelmingly described deaths as peaceful and sometimes even as a "good death." There was (for some) a significant "burden of witness" associated with the length of time it took the person to die and/or distressing changes in their appearance. Most continued to voice ethical objections to the manner of death while considering it "the least worst" option in the circumstances.

CONCLUSION

Staff need to be aware of the distinctive issues around care for this patient group and their families. It is important to challenge misinformation and initiate honest discussions about feeding-tube withdrawal and end-of-life care for these patients. Families (and staff) need better support in managing the "burden of witness" associated with these deaths.

[Parkinson's disease, Alzheimer's disease and oncological diseases in residential geriatric care : Pain frequency and selected healthcare features in comparison]

BACKGROUND

Adequate pain management and palliative care structures are of significant importance in residential nursing homes. Whilst professional pain treatment and palliative care measures are frequently implemented for residents with oncological diseases, this is often not the case for residents with neurological disorders. Such a potential undertreatment is even more challenging when the means of interaction and communication with affected persons are aggravated by impairments in cognitive function.

OBJECTIVE

To examine differences in selected health care service characteristics between nursing home residents with Parkinson's disease, Alzheimer's disease and residents diagnosed with cancer.

MATERIAL AND METHODS

Secondary data analysis of residents' survey and medical record data from 13 nursing homes as part of the study "Action Alliance Pain-free City Münster".

RESULTS

Compared with residents with Parkinson's disease and cancer, nursing home residents with Alzheimer's disease exhibited significantly more severe impairment in cognitive function, less additional pain-associated diagnoses, shorter length of stay in nursing homes and more indications of pain.

CONCLUSION

The generally high level of pain in all observed residents elucidates the principle necessity of adequate pain assessment and an interprofessional pain treatment. Furthermore, there seems to be a still unmet need for specifically adapted pain management strategies especially for the steadily increasing number of people with Parkinson's disease and Alzheimer's disease living in nursing homes. This should be a future high priority task for (nursing) practice and research against the background of the vulnerability of nursing home populations.

Quality versus quantity in end-of-life choices of cancer patients and support persons: a discrete choice experiment

OBJECTIVES

To explore in a sample of medical oncology outpatients and their nominated support persons (SPs): (1) the relative influence of pain, consciousness and life extension on end-of-life choices using a discrete choice experiment (DCE); (2) the extent to which SPs can predict the choices of index patients and (3) whether having a previous end-of-life discussion was associated with dyad agreement.

METHODS

Adult medical oncology patients and their SPs were approached for consent to complete a survey containing a DCE. Participants chose between three unlabelled care scenarios characterised by three attributes: pain (mild, moderate or severe), consciousness (some, half or most of time) and extension of life (1, 2 or 3 weeks). Respondents selected (1) most-preferred and (2) least-preferred scenarios within each question. SPs answered the same questions but from patient's perspective.

RESULTS

A total of 110 patients and 64 SPs responded overall (42 matched patient-SP dyads). For patients, pain was the most influential predictor of most- and least-preferred scenarios (z = 12.5 and z = 12.9). For SPs, pain was the only significant predictor of most and least-preferred scenarios (z = 9.7 and z = 11.5). Dyad agreement was greater for choices about least- (69%) compared to most-preferred scenarios (55%). Agreement was slightly higher for dyads reporting a previous EOL discussion (68 versus 48%; p = 0.065).

CONCLUSION

Patients and SPs place significant value on avoiding severe pain when making end-of-life choices, over and above level of consciousness or life extension. People's views about end-of-life scenarios they most as well as least prefer should be sought.

Interventions in hospitalised patients with cancer: the importance of impending death awareness

Objectives

Burdensome and futile interventions with the aim of prolonging life should be avoided in dying patients. However, current clinical practice has hardly been investigated.

We examined the number and type of diagnostic and therapeutic medical interventions in hospitalised patients with cancer in their last days of life. In addition, we investigated if physician awareness of impending death affected the use of these interventions.

Methods

Questionnaire study and medical record study. Attending physicians of patients who died in a university hospital between January 2010 and June 2012 were asked whether they had been aware of the patient’s impending death. The use of diagnostic and therapeutic interventions and medications was assessed by studying patients’ charts. We included 131 patients.

Results

In the last 72 and 24 hours of life, 59% and 24% of the patients received one or more diagnostic interventions, respectively. Therapeutic interventions were provided to 47% and 31%. In the last 24 hours of life, patients received on average 5.8 types of medication.

Awareness of a patient’s impending death was associated with a significant lower use of diagnostic interventions (48% vs 69% in the last 72 hours; 11% vs 37% in the last 24 hours) and several medications that potentially prolong life (eg, antibiotics and cardiovascular medication).

Conclusions

Many patients with cancer who die in hospital receive diagnostic and therapeutic interventions in the last days of life of which their advantages are questionable. To improve end-of-life care, medical care should be adapted.

Performance Status, Prognostic Scoring, and Parenteral Nutrition Requirements Predict Survival in Patients with Advanced Cancer Receiving Home Parenteral Nutrition

We describe a cohort of Home Parenteral Nutrition (HPN) patients with advanced cancer in order to identify factors affecting prognosis. Demographic, anthropometric, biochemical and medical factors, Karnofsky Performance Status (KPS), Glasgow Prognostic Score (GPS), and PN requirements were recorded. Univariate and multivariate analyses were performed including Kaplan-Meier curves, Cox Regression, and correlation analyses. In total, 107 HPN patients (68 women, 39 men, mean age 57 yr) with advanced cancer were identified. The main indications for HPN were bowel obstruction (74.3%) and high output ostomies (14.3%). Cancer cachexia was present in 87.1% of patients. The hazard ratio (HR) for upper gastrointestinal and "other" cancers vs. gynaecological malignancy was 1.75 (p = 0.077) and 2.11 (p = 0.05), respectively. KPS score, GPS, PN volume, and PN potassium levels significantly predicted survival (HR_{KPS ≥50 vs <50} = 0.47; HR_{GPS = 2 vs. GPS = 0} = 3.19). In multivariate analysis, KPS and GPS remained significant predictors (p < 0.05), whilst PN volume reached borderline significance (p = 0.094). Survival was not significantly affected by the presence of metastatic disease, previous or concurrent surgery, chemo-radiotherapy, or indication for HPN (p > 0.05). Most patients passed away in their homes or hospice (77.9%). Performance status, prognostic scoring, and PN requirements may predict survival in patients with advanced cancer receiving HPN.

Advance directives: cancer patients' preferences and family-based decision making

BACKGROUND

Advance directives are a sensitive issue among traditional Chinese people, who usually refrain from mentioning this topic until it is imperative. Medical decisions for cancer patients are made by their families, and these decisions might violate patients' personal will.

OBJECTIVES

This study aimed to examine the acceptance of advance directives among Chinese cancer patients and their families and patient participation in this procedure and, finally, to analyze the moral risk involved.

RESULTS

While 246 patients and their family members refused official discussion of an advance directive, the remaining 166 patients and their families accepted the concept of an advance directive and signed a document agreeing to give up invasive treatment when the anti-cancer treatment was terminated. Of these, only 24 patients participated in the decision making. For 101 patients, anti-cancer therapy was ended prematurely with as many as 37 patients not told about their potential loss of health interests.

MATERIALS AND METHODS

Participants were 412 adult cancer patients from 9 leading hospitals across China. An advance directive was introduced to the main decision makers for each patient; if they wished to sign it, the advance directive would be systematically discussed. A questionnaire was given to the oncologists in charge of each patient to evaluate the interaction between families and patients, patients' awareness of their disease, and participation in an advance directive.

CONCLUSIONS

Advance directives were not widely accepted among Chinese cancer patients unless anti-cancer therapy was terminated. Most cancer patients were excluded from the discussion of an advance directive.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

The Role of Intravenous Fluids and Enteral or Parenteral Nutrition in Patients with Life-limiting Illness

The decision of whether or not to use artificial nutrition or hydration is one with which many health care providers, patients, and families struggle. These decisions are particularly challenging in the setting of life-limiting illness, which is often associated with a prolonged decline because of medical advances in these patient populations. A patient-centered and family-centered approach helps to attain high-quality care in this special population.

The Troubling Trichotomy 10 Years Later: Where Are We Now?

A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.

ESPEN guideline on ethical aspects of artificial nutrition and hydration

BACKGROUND

The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient.

METHODS

The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members.

RESULTS

The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project

BACKGROUND

The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation.

STUDY DESIGN

Quality improvement project.

SETTINGS & PARTICIPANTS

Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?").

QUALITY IMPROVEMENT PLAN

Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form.

OUTCOMES

Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment.

MEASUREMENTS

Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year.

RESULTS

Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001).

LIMITATIONS

Sample size and possible nonrepresentative dialysis population.

CONCLUSIONS

Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.

Education Intervention “Caregivers Like Me” for Latino Family Caregivers Improved Attitudes Toward Professional Assistance at End-of-life Care

Objective:

This study explores the ability of a culturally sensitive and case-based education intervention, Caregivers Like Me, to improve knowledge and attitudes regarding end-of-life (EOL) resources among Latino caregivers.

Methods:

A multicentered, cross-sectional study of Latino communities from different geographical regions and cultural backgrounds. An educational intervention was administered to family caregivers of Latino elders using a case-based video “ telenovela” and pretest–posttest questionnaires.

Results:

Participants (N = 145) were mostly females (79%) with mean age of 56 ± 15 years. They reported active learning from intervention (91%) and high satisfaction (92%) with educational experience. Both caregiver stress self-awareness and willingness to accept professional help improved significantly from pretest to posttest.

Conclusion:

A culturally sensitive educational intervention increased Latino caregivers’ self-awareness about caregiver stress and the need to consider professional assistance for EOL care.

Nonconsensual withdrawal of nutrition and hydration in prolonged disorders of consciousness: authoritarianism and trustworthiness in medicine

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness (PDOC) in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration (CANH). This withdrawal is deemed necessary because patients in PDOC can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of "best interests" rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person's best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public's trust in the integrity of the medical profession.