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Graça J, Vasconcelos de Matos L, Baleiras AM, Ferreira F, Costa R, Pinto MM, Martins A. Therapeutic Futility in Terminal Cancer Patients: A Retrospective and Observational Study. Cureus 2021; 13:e14073. [PMID: 33777589 PMCID: PMC7988361 DOI: 10.7759/cureus.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Advanced cancer patients often need therapy for symptomatic control, in addition to cancer and other disease treatments. As the cancer disease progresses and life expectancy decreases, there should be a change in the goal of care. If this change is not accompanied by therapeutic adjustments, there is a risk of maintaining useless and ineffective treatments, as well as potential harmful drug interactions. This study analyzed the prevalence of therapeutic futility in patients with advanced cancer disease. Materials and methods This was a retrospective and observational single-center study, that included advanced cancer patients who died during the hospital stay, at a University Hospital in Lisbon, Portugal. Demographic and clinical data were collected. A Palliative Prognostic Score (PaP) was used to stratify patients according to their prognosis group. An analysis of the prescribed therapy was performed to quantify the "potentially inappropriate medications" (PIMs) and "inappropriate medications" (IMs), at admission and 24 hours prior to the patient's death. Results Over 140 patients were included. On the first day of hospitalization, 119 patients (85%) were exposed to at least one IM or PIM and 100 patients (71%) were still exposed to at least one IM or PIM in the last 24 hours of life. Regarding chemotherapy, 66 patients (47%) had treatment in the last two months of life, 38 (27%) in the last month, and 17 (12%) in the last two weeks prior to death. Therapeutic simplification (suspension of IMs and reduction of at least 50% of PIMs during hospitalization) was performed in 43% of the overall population and was higher in PaP score group C, but not statistically significant (p=0.09). The patient's inclusion in PaP score group C and inpatient consultation by the palliative care team were independent predictors of therapeutic simplification. Discussion There is an effort to achieve greater therapeutic suitability in palliative patients. However, many patients maintain futile and disproportionate therapy at the end of life (EoL). In many cases, systemic cancer treatment is performed until quite late in the course of the disease. The prescription of PIMs was significantly higher than that of IMs, which could be expected given their definition. A shorter life expectancy at admission led to a greater therapeutic simplification, as well as an intervention by the Palliative Care Team, which can be explained by the more focused approach towards quality-of-life improvement and symptomatic control. Different than expected the prescription of supportive therapies at hospital admission was not a predictor of therapeutic simplification. Although there was a reduction in IMs and PIMs in the studied population, and therapeutic simplification occurred in one fraction of the patients, the fact is that more than half of the patients evaluated did not undergo therapeutic simplification as defined in this work. Conclusion It appears that there is an effort to achieve greater therapeutic suitability in palliative patients, however, many patients maintain futile therapy at the EoL. It is of paramount importance to change the standard of care in this setting, to privilege a more patient-focused approach and tailored therapy, and to prioritize symptomatic control and quality-of-life improvement.
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Affiliation(s)
- Joana Graça
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | | | - Ana Mafalda Baleiras
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Filipa Ferreira
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Rui Costa
- Internal Medicine, Hospital da Luz, Lisboa, PRT
| | - Marta M Pinto
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Ana Martins
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
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Zakaria HM, Llaniguez JT, Telemi E, Chuang M, Abouelleil M, Wilkinson B, Chandra A, Boyce-Fappiano D, Elibe E, Schultz L, Siddiqui F, Griffith B, Kalkanis SN, Lee IY, Chang V. Sarcopenia Predicts Overall Survival in Patients with Lung, Breast, Prostate, or Myeloma Spine Metastases Undergoing Stereotactic Body Radiation Therapy (SBRT), Independent of Histology. Neurosurgery 2019; 86:705-716. [DOI: 10.1093/neuros/nyz216] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/11/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
BACKGROUND
Predicting survival of patients with spinal metastases would help stratify treatments from aggressive to palliation.
OBJECTIVE
To evaluate whether sarcopenia predicts survival in patients with lung, breast, prostate, or multiple myeloma spinal metastases.
METHODS
Psoas muscle measurements in patients with spinal metastasis were taken from computed tomography scans at 2 time points: at first episode of stereotactic body radiation therapy (SBRT) and from the most recent scan available. Overall survival and hazard ratios were calculated with multivariate cox proportional hazards regression analyses.
RESULTS
In 417 patients with spinal metastases, 40% had lung cancer, 27% breast, 21% prostate, and 11% myeloma. Overall survival was not associated with age, sex, ethnicity, levels treated, or SBRT volume. Multivariate analysis showed patients in the lowest psoas tertile had shorter survival (222 d, 95% CI = 185-323 d) as compared to the largest tertile (579 d, 95% CI = 405-815 d), (HR1.54, P = .005). Median psoas size as a cutoff value was also strongly predictive for survival (HR1.48, P = .002). Survival was independent of tumor histology. The psoas/vertebral body ratio was also successful in predicting overall survival independent of tumor histology and gender (HR1.52, P < .01). Kaplan–Meier survival curves visually represent survival (P = .0005).
CONCLUSION
In patients with spine metastases, psoas muscle size as a hallmark of frailty/sarcopenia is an objective, simple, and effective way to identify patients who are at risk for shorter survival, regardless of tumor histology. This information can be used to help with surgical decision making in patients with advanced cancer, as patients with small psoas sizes are at higher risk of death.
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Affiliation(s)
- Hesham Mostafa Zakaria
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Jeremy T Llaniguez
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Edvin Telemi
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Matthew Chuang
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Mohamed Abouelleil
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Brandon Wilkinson
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Ankush Chandra
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - David Boyce-Fappiano
- Department of Public Health Sciences, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Erinma Elibe
- Department of Public Health Sciences, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Lonni Schultz
- Department of Radiology, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Farzan Siddiqui
- Department of Public Health Sciences, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Brent Griffith
- Department of Radiation Oncology, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Steven N Kalkanis
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Ian Yu Lee
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Victor Chang
- Department of Neurosurgery, Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
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Lewis E, Cardona-Morrell M, Ong KY, Trankle SA, Hillman K. Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review. Palliat Med 2016; 30:807-24. [PMID: 26951066 DOI: 10.1177/0269216316637239] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference. AIM To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions. DESIGN Systematic review of the English language articles published from January 2000 to April 2015. DATA SOURCES EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. RESULTS A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. CONCLUSION Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.
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Affiliation(s)
- Ebony Lewis
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia
| | - Magnolia Cardona-Morrell
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia
| | - Kok Y Ong
- School of Medicine, Western Sydney University, Campbelltown NSW 2560, Australia
| | - Steven A Trankle
- School of Medicine, Western Sydney University, Campbelltown NSW 2560, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, NSW, Australia Intensive Care Unit, Liverpool Hospital, Liverpool NSW 2170, Australia
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Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28:456-69. [PMID: 27353273 DOI: 10.1093/intqhc/mzw060] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
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Affiliation(s)
- M Cardona-Morrell
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia
| | - Jch Kim
- School of Medicine, Ground floor, 30, Western Sydney University, Narellan Road & Gilchrist Drive, Campbelltown NSW 2560, Australia
| | - R M Turner
- School of Public Health and Community Medicine, Level 2, Samuels Building, Samuels Ave, The University of New South Wales, Kensington NSW 2033, Australia
| | - M Anstey
- Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Perth WA 6009, Australia
| | - I A Mitchell
- Intensive Care Unit, Building 12, Level 3, Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
| | - K Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia Intensive Care Unit, Level 2, Liverpool Hospital, Elizabeth St & Goulburn St, Liverpool NSW 2170, Australia
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Kotlinska-Lemieszek A, Paulsen O, Kaasa S, Klepstad P. Polypharmacy in patients with advanced cancer and pain: a European cross-sectional study of 2282 patients. J Pain Symptom Manage 2014; 48:1145-59. [PMID: 24780183 DOI: 10.1016/j.jpainsymman.2014.03.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 11/17/2022]
Abstract
CONTEXT Patients with advanced cancer need multiple drugs to control symptoms and to treat cancer and concomitant diseases. At the same time, the goal of treatment changes as life expectancy becomes limited. This results in a risk for polypharmacy, maintained use of unneeded drugs, and drug-drug interactions (DDIs). OBJECTIVES The aim of the study was to analyze the use of medications and to identify unneeded drugs, and drugs and drug combinations with a risk for DDIs in a cohort of advanced cancer pain patients, defined by a need for a World Health Organization analgesic ladder Step III opioid. METHODS All drugs taken within a study day by cancer patients receiving opioids for moderate or severe pain (Step III opioids) were analyzed. Nonopioids and adjuvants were analyzed for their use across countries. Unneeded medications and drugs and drug combinations with a risk for pharmacodynamic and pharmacokinetic DDIs were identified on the basis of published literature and electronic resources. RESULTS In total, 2282 patients from 17 centers in 11 European countries were included. They received a mean of 7.8 drugs (range 1-20). Over one-quarter used 10 or more medications. The drugs and drug classes most frequently coadministered with opioids were proton pump inhibitors, laxatives, corticosteroids, paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, metoclopramide, benzodiazepines, anticoagulants, antibiotics, anticonvulsants, diuretics, and antidepressants. The use of nonopioids and essential adjuvants varied across countries. Approximately 45% of patients received unnecessary or potentially unnecessary drugs, and about 7% were given duplicate or antagonizing agents. Exposures to DDIs were frequent and increased the risk of sedation, gastric ulcerations, bleedings, and neuropsychiatric and cardiac complications. Many patients were exposed to pharmacokinetic DDIs involving cytochrome P450, including about 58% who used a Step III opioid CYP3A4 (izoenzyme of cytochrome P450) substrate, and more than 10% who were given major CYP3A4 inhibitors or inducers. CONCLUSION Patients with cancer treated with a World Health Organization Step III opioid use a high number of drugs. Nonopioid analgesics and corticosteroids are frequently used, but different patterns of use between countries were found. Many patients receive unneeded drugs and are at risk of serious DDIs. These findings demonstrate that drug therapy in these patients needs to be evaluated continuously.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Department of Palliative Medicine Karol Marcinkowski University of Medical Sciences, Poznan, Poland; Hospice Palium, University Hospital of the Lord's Transfiguration, Poznan, Poland.
| | - Ornulf Paulsen
- Palliative Care Unit, Department of Medicine, Telemark Hospital Trust, Skien, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesiology and Intensive Care Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Medical oncologists' perception of palliative care programs and the impact of name change to supportive care on communication with patients during the referral process. A qualitative study. Palliat Support Care 2013; 11:397-404. [PMID: 23302500 DOI: 10.1017/s1478951512000685] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In a simultaneous care model, patients have concurrent access to both cancer-directed therapies and palliative care. As oncologists play a critical role in determining the need/timing of referral to palliative care programs, their understanding of the service and ability to communicate this with patients is of paramount importance. Our study aimed to examine oncologists' perceptions of the supportive care program at M.D. Anderson Cancer Center, and to determine whether renaming “palliative care” to “supportive care” influenced communication regarding referrals. METHOD This qualitative study used semi-directed interviews, and we analyzed data using grounded theory and qualitative methods. RESULTS We interviewed 17 oncologists. Supportive care was perceived as an important time-saving application, and symptom control, transitioning to end-of-life care, family counseling, and improving patients' ability to tolerate cancer therapies were cited as important functions. Although most claimed that early referrals to the service are preferable, oncologists identified several challenges, related to the timing and communication with patients regarding the referral, as well as with the supportive care team after the referral was made. Whereas oncologists stated that the name change had no impact on their referral patterns, the majority supported it, as they perceived their patients preferred it. SIGNIFICANCE OF RESULTS Although the majority of oncologists favorably viewed supportive care, communication barriers were identified, which need further confirmation. Simultaneous care models that effectively incorporate palliative care with cancer treatments need further development.
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Weisleder P, Perkins E, McLaughlin A. Child neurologists as health care surrogate for imperiled children. J Child Neurol 2011; 26:295-301. [PMID: 21098330 DOI: 10.1177/0883073810380048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We explored child neurologists' attitudes toward taking on the role of health care surrogate for terminally ill children. Physician members of the Child Neurology Society were sent a 16-question survey via email. Of the assumed 1050 recipients, 116 (11%) answered the questionnaire. Most individuals who have been in practice less than 11 years indicated having received formal end-of-life decision-making education either during medical school or residency. Conversely, a minority of participants who have been in practice more than 11 years indicated having received such education. Regardless of years in practice, 54% (n = 61 of 112) of participants would feel at least ''somewhat comfortable'' independently making life-limiting decisions for imperiled patients. The number increased to 80% if the decision were made within the context of a multidisciplinary team. Taking our data and the experience published by others into consideration, we suggest a method for establishing such a team.
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Affiliation(s)
- Pedro Weisleder
- Division of Child Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio 43205, USA.
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Buyx AM, Friedrich DR, Schöne-Seifert B. Marginale Wirksamkeit als Posteriorisierungskriterium – Begriffsklärungen und ethisch relevante Vorüberlegungen. Ethik Med 2009. [DOI: 10.1007/s00481-009-0001-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer 2008; 17:745-8. [PMID: 19030900 DOI: 10.1007/s00520-008-0541-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/07/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cancer patients usually take many medications. The proportion of patients with advanced cancer who are taking futile drugs is unknown. MATERIALS AND METHODS We retrospectively reviewed the charts of all consecutive ambulatory patients with advanced cancer and who were receiving supportive care exclusively at palliative care clinics, Princess Margaret Hospital, to gather information on futile medications used by them. Futile medications were defined as unnecessary (when no short-term benefit to patients with respect to survival, quality of life, or symptom control was anticipated) or duplicate (two or more drugs from the same pharmacological class). Summary statistics were used to describe the results. RESULTS From November 2005 to July 2006, 82 (22%) of 372 patients were taking at least one futile medication before consultation; after initial consultation, this proportion dropped to 20% (78): 70 patients were taking unnecessary medications, while eight were on duplicate medications. The most frequent unnecessary medications used by patients were statins (56%). The most common duplicate medication involved the use of two different benzodiazepines (seven patients). CONCLUSION About one fifth of cancer outpatients at the end of life take futile medications, most commonly statins. Prospective and population-based studies are warranted to further evaluate the magnitude and consequences of futile medication use in oncology.
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Affiliation(s)
- Rachel P Riechelmann
- Department of Internal Medicine, Federal University of Sao Paulo, R: Luisiania 255, Apt 11, São Paulo, SP 04560-020, Brazil.
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Abstract
Resuscitability is a concept often used during the resuscitation of injured patients but remains unnamed, unexplored, and undefined. This article explores resuscitability as it pertains to nurses caring for adult trauma patients for the purposes of concept development. After a review of the literature, dimensions discovered include physiologic, legal, ethical, and societal. Development of the concept of resuscitability can be used to address issues related to trauma resuscitations. Trauma nurses care for severely injured patients on each of the dimensional levels identified and thus understanding the meaning of resuscitability will help nurses better care for their injured patients.
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Hammel JF, Sullivan AM, Block SD, Twycross R. End-of-Life and Palliative Care Education for Final-Year Medical Students: A Comparison of Britain and the United States. J Palliat Med 2007; 10:1356-66. [DOI: 10.1089/jpm.2007.0059] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- James F. Hammel
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Green College, Oxford University, United Kingdom
- Mount Sinai Medical Center, New York, New York
| | - Amy M. Sullivan
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, and Harvard Medical School Center for Palliative Care, Massachusetts
| | - Susan D. Block
- Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, and Harvard Medical School Center for Palliative Care, Massachusetts
| | - Robert Twycross
- Emeritus Clinical Reader in Palliative Medicine, Oxford University, United Kingdom
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McGrath P, Holewa H. Missed opportunities: nursing insights on end-of-life care for haematology patients. Int J Nurs Pract 2006; 12:295-301. [PMID: 16942518 DOI: 10.1111/j.1440-172x.2006.00585.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There is now extensive consumer research to indicate that patients with haematological malignancies are not receiving appropriate or timely referrals to the palliative system. This paper begins to explore the issue from the professional perspective by presenting findings from haematology nurses on their experience with terminal care. The nursing insights have been gathered through open-ended interviews with a national sample of nurses with extensive experience in haematology in both public and private hospitals throughout Australia. The findings resonate with the previous consumer research in that all the acute care nurses affirmed that it is their belief, based on their professional experience, that patients from these diagnostic groups typically die in the acute ward dealing with escalating technology and invasive treatments. For some, the statements could be qualified by the satisfaction that they worked in a haematology unit, aware of the death-denying issues, trying to address the problem. Others, caught in a 'refractory' subculture (i.e. a subculture with a negative perception of palliative care), outlined the factors driving the lack of integration for their specific hospital. The focus of the discussion of findings is on the latter.
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Affiliation(s)
- Pam McGrath
- NH&MRC Senior Research Fellow, International Program for Psycho-Social Health Research, Central Queensland University, Brisbane, Queensland, Australia.
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Neerkin J, Riley J. Ethical aspects of palliative care in lung cancer and end stage lung disease. Chron Respir Dis 2006; 3:93-101. [PMID: 16729767 DOI: 10.1191/1479972306cd104rs] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Over 50 000 people die per year in England and Wales from lung cancer and chronic obstructive pulmonary disease (COPD). Current National Institute for Clinical Evidence guidelines for lung cancer and COPD recommend provision of palliative care for those that need it. Palliative care historically has accepted patients with cancer, but access to patients with non-malignant disease has been more sporadic. This paper aims to highlight the many ethical dilemmas faced when treating both these groups of patients. These include issues surrounding the form of treatment or treatment withdrawal, the burden on the patient or on the health service; or conducting research in terminally ill patients.
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Affiliation(s)
- J Neerkin
- The Royal Marsden Hospital Foundation Trust, London, UK
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14
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von Gruenigen VE, Daly BJ. Treating ovarian cancer patients at the end of life: when should we stop? Gynecol Oncol 2005; 99:255-6. [PMID: 16198397 DOI: 10.1016/j.ygyno.2005.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 09/09/2005] [Indexed: 11/19/2022]
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Hofmann B, Håheim LL, Søreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005; 92:802-9. [PMID: 15962261 DOI: 10.1002/bjs.5104] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base. METHOD AND RESULTS Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided. CONCLUSION Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.
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Affiliation(s)
- B Hofmann
- Section for Medical Ethics, University of Oslo, Norway.
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von Gruenigen VE, Daly BJ. Futility: clinical decisions at the end-of-life in women with ovarian cancer. Gynecol Oncol 2005; 97:638-44. [PMID: 15863171 DOI: 10.1016/j.ygyno.2005.01.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Revised: 01/24/2005] [Accepted: 01/24/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a review of the clinical meaning of futility, discuss current normative uses of futility assessments and propose guidelines for clinicians to use in dialogue regarding treatment decisions for patients with advanced ovarian cancers. METHODS We performed a MEDLINE literature search of relevant clinical articles for this review that discussed futility and the application to women with ovarian cancer. RESULTS Medical futility refers to treatments that serve no physiologic, quantitative or qualitative meaningful purpose. Despite the growth in options focused on symptom management rather than disease eradication, including hospice programs and the more recent development of palliative care programs, there is evidence that many patients continue to receive aggressive interventions, including chemotherapy, until days before their death. While the legal and moral acceptability of treatment limitation is well established, clarity in establishing goals of care, timing of the transition from cure to palliation and communication of specific decisions to withhold further aggressive interventions remain problematic for both patients and clinicians. CONCLUSIONS There continues to be a distinct need for both better understanding of the dynamics of patient choice and increased education of physicians in addressing end-of-life care planning. It is essential that we continue to test specific communication and supportive interventions that will improve our ability to help patients avoid the burden of futile therapy while maintaining hope.
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Affiliation(s)
- Vivian E von Gruenigen
- Department of Reproductive Biology, Division of Gynecologic Oncology, University MacDonald Women's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Beji NK, Reis N, Bag B. Views of patients with gynecologic cancer about the end of life. Support Care Cancer 2005; 13:658-62. [PMID: 15700132 DOI: 10.1007/s00520-004-0747-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 11/02/2004] [Indexed: 10/25/2022]
Abstract
This study was designed as a descriptive work assessing the reactions of gynecologic cancer patients to poor prognosis, determining their desires for the location of terminal care, and their preferences about life-sustaining technology. The study was carried out between 2002 and 2003 in a gynecologic oncology clinic of a university hospital located in Istanbul. Data were collected through interviews with 68 patients with gynecologic cancers. Collected data were analyzed through content analysis. It was found that survival is utterly important for the patients and that they wish to stay at hospitals as inpatients and receive life-sustaining treatments during the end-stage disease.
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Affiliation(s)
- Nezihe Kizilkaya Beji
- Department of Obstetric and Gynecologic Nursing, Florence Nightingale College of Nursing, Istanbul University, 80270 Sisli, Istanbul, Turkey
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Meltzer LS, Huckabay LM. Critical Care Nurses’ Perceptions of Futile Care and Its Effect on Burnout. Am J Crit Care 2004. [DOI: 10.4037/ajcc2004.13.3.202] [Citation(s) in RCA: 276] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Nurses’ perceptions of futile care may lead to emotional exhaustion.
• Objectives To determine the relationship between critical care nurses’ perceptions of futile care and its effect on burnout.
• Methods A descriptive survey design was used with 60 critical care nurses who worked full-time and had a minimum of 1 year of critical care experience at the 2 participating hospitals (350–470 beds). Subjects completed a survey on demographics, the Moral Distress Scale, and the Maslach Burnout Inventory. Six research questions were tested. The results of the following question are presented: Is there a relationship between frequency of moral distress situations involving futile care and emotional exhaustion?
• Results A Pearson product moment correlational analysis indicated a significant positive correlation between the score on the emotional exhaustion subscale of the Maslach Burnout Inventory and the score on the frequency subscale of the Moral Distress Scale. Moral distress accounted for 10% of the variance in emotional exhaustion. Demographic variables of age, education, religion, and rotation between the critical care units were significantly related to the major variables.
• Conclusions In critical care nurses, the frequency of moral distress situations that are perceived as futile or nonbeneficial to their patients has a significant relationship to the experience of emotional exhaustion, a main component of burnout.
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Warner TD, Roberts LW, Smithpeter M, Rogers M, Roberts B, McCarty T, Franchini G, Geppert C, Obenshain SS. Uncertainty and opposition of medical students toward assisted death practices. J Pain Symptom Manage 2001; 22:657-67. [PMID: 11495712 DOI: 10.1016/s0885-3924(01)00314-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To explore medical students' views of assisted death practices in patient cases that describe different degrees and types of physical and mental suffering, an anonymous survey was administered to all students at one medical school. Respondents were asked about the acceptability of assisted death activities in five patient vignettes and withdrawal of life support in a sixth vignette. In the vignettes, actions were performed by four possible agents: the medical student personally; a referral physician; physicians in general; or non-physicians. Of 306 medical students, 166 (54%) participated. Respondents expressed opposition or uncertainty about assisted death practices in the five patient cases that illustrated severe forms of suffering which were secondary to amyotrophic lateral sclerosis, treatment-resistant depressive and somatoform disorders, antisocial and sexually violent behavior, or AIDS. Students supported the withdrawal of life support in the sixth vignette depicting exceptional futility secondary to AIDS. Students were especially opposed to their own involvement and to the participation of non-physicians in assisted death activities. Differences in views related to sex, religious beliefs, and personal philosophy were found. Medical students do not embrace assisted death practices, although they exhibit tolerance regarding the choices of medical colleagues. How these attributes of medical students will translate into future behaviors toward patients and peers remains uncertain. Medical educators must strive to understand the perspectives of physicians-in-training. Expanded, empirically informed education that is attuned to the attitudes of medical students may be helpful in fulfilling the responsibility of imparting optimal clinical care skills.
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Affiliation(s)
- T D Warner
- Department of Psychiatry, University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131, USA
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Abstract
As palliative care emerges as a respected and important component of contemporary health care, ethical issues will arise that confront and contest the provision of medical care. The basic principles of medical ethics, embodied in beneficence, nonmaleficence, autonomy, and justice, guide primary care physicians in dealing with dying patients. This article will discuss the basic ethical principles and the principle of double effect, decision-making capacity, advance directives, withholding and withdrawing life-sustaining therapy, futility, artificial nutrition and hydration, do-not-resuscitate orders, and physician-assisted suicide and euthanasia.
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Affiliation(s)
- P Rousseau
- Department of Adult Development and Aging, Arizona State University, Tempe, USA.
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Gillis TA, Cheville AL, Worsowicz GM. Cardiopulmonary rehabilitation and cancer rehabilitation. 4. Oncologic rehabilitation. Arch Phys Med Rehabil 2001. [DOI: 10.1016/s0003-9993(01)80042-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Coulson S, Phelan L. Clinical research in paediatric oncology and the role of the research nurse in the UK. Eur J Oncol Nurs 2000; 4:154-61. [PMID: 12849646 DOI: 10.1054/ejon.2000.0100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Survival rates for childhood cancer have improved considerably as new drugs, treatment protocols and supportive therapies have developed through clinical trials. Such studies take a considerable amount of time and organization and alongside scientific and medical staff the research nurse plays a vital role. The facets of this role will be outlined in this paper. Involvement begins at an early stage of study development and includes applying for Research Ethics Committee approval of the project. Once the study has opened the research nurse is then responsible for patient recruitment, monitoring and follow-up. The research nurse works within a team but also with a degree of autonomy ensuring that standards of patient care are maintained by adhering to guidelines for clinical research in general and those aimed at children specifically. Providing detailed information and support to the child and family, staff and outside agencies are other notable aspects of the post. The role of the research nurse continues to develop, as clinical trials maintain a significant role in improving the treatment for childhood cancer.
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Affiliation(s)
- S Coulson
- Paediatric Oncology, St. James's University Hospital, Leeds, UK
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