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Martinsson L, Strang P, Lundström S, Hedman C. Parenteral Hydration in Dying Patients With Cancer: A National Registry Study. J Pain Symptom Manage 2024; 67:384-392. [PMID: 38342476 DOI: 10.1016/j.jpainsymman.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
CONTEXT Clinically assisted hydration during end-of-life care among patients with cancer is controversial; practice varies between clinical settings and countries, and there is a lack of evidence. OBJECTIVES To examine whether breathlessness, respiratory secretion, or confusion correlates with receiving parenteral hydration during end of life, adjusted for sex, age, and place of death. METHODS The Swedish Register of Palliative Care database was used to collect data about the usage of parenteral hydration during the last day of life, and the occurrence of three symptoms during the last week. Adults dying from cancer during 2011-2021 in hospitals, in residential care homes, and within specialized palliative care were included. Correlation between parenteral hydration and symptoms was examined using χ2-test and logistic regression. RESULTS A total of 147,488 patients were included in the study. Parenteral hydration was more often prescribed to younger persons, to men, and in acute hospitals (compared to other settings), p < 0.001 in all three comparisons. Patients with hematological malignancies (20%) and ovarian cancer (16%) were most likely to receive parenteral hydration, while those with brain tumors (6%) were least likely. The presence of all three analyzed symptoms during the last week (breathlessness, respiratory secretion, and confusion) were significantly correlated with having received parenteral hydration during the last day of life (p < 0.001). In the final logistic regression model adjusted for age, sex, and place of death, the only symptom with remaining correlation to parenteral hydration was breathlessness (OR 1.56, 95% CI 1.50-1.6). CONCLUSION There is an association between parenteral hydration and increased breathlessness in patients with cancer. Provision of parenteral hydration is more prevalent in men, younger patients, and those with hematological malignancies or ovarian cancer, and most widespread in acute hospital settings.
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Affiliation(s)
- Lisa Martinsson
- Department of Radiation Sciences, Oncology (L.M.), Umeå University, Umeå, Sweden.
| | - Peter Strang
- Department of Oncology-Pathology (P.S., S.L.), Karolinska Institutet, Stockholm, Sweden; R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Staffan Lundström
- Department of Oncology-Pathology (P.S., S.L.), Karolinska Institutet, Stockholm, Sweden; R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Christel Hedman
- R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Molecular Medicine and Surgery (C.H.), Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences Lund (C.H.), Lund University, Lund, Sweden
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Hayes J, Bruera E, Crawford G, Fleury M, Santos M, Thompson J, Davies A. Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted hydration in patients with advanced cancer. Support Care Cancer 2024; 32:228. [PMID: 38478135 PMCID: PMC10937805 DOI: 10.1007/s00520-024-08421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
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.
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Affiliation(s)
- Jo Hayes
- St. Catherine's Hospice, Crawley, UK
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Gregory Crawford
- University of Adelaide and Northern Adelaide Local Health Network, Adelaide, Australia
| | - Mapi Fleury
- Department of Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | | | | | - Andrew Davies
- Trinity College Dublin, University College Dublin, Our Lady's Hospice, Dublin, Ireland.
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Buchan EJ, Haywood A, Syrmis W, Good P. Medically assisted hydration for adults receiving palliative care. Cochrane Database Syst Rev 2023; 12:CD006273. [PMID: 38095590 PMCID: PMC10720602 DOI: 10.1002/14651858.cd006273.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND Many people receiving palliative care have reduced oral intake during their illness, and particularly at the end of their life. Management of this can include the provision of medically assisted hydration (MAH) with the aim of improving their quality of life (QoL), prolonging their life, or both. This is an updated version of the original Cochrane Review published in Issue 2, 2008, and updated in February 2011 and March 2014. OBJECTIVES To determine the effectiveness of MAH compared with placebo and standard care, in adults receiving palliative care on their QoL and survival, and to assess for potential adverse events. SEARCH METHODS We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, CANCERLIT, CareSearch, Dissertation Abstracts, Science Citation Index and the reference lists of all eligible studies, key textbooks, and previous systematic reviews. The date of the latest search conducted on CENTRAL, MEDLINE, and Embase was 17 November 2022. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) of studies of MAH in adults receiving palliative care aged 18 and above. The criteria for inclusion was the comparison of MAH to placebo or standard care. DATA COLLECTION AND ANALYSIS Three review authors independently reviewed titles and abstracts for relevance, and two review authors extracted data and performed risk of bias assessment. The primary outcome was QoL using validated scales; secondary outcomes were survival and adverse events. For continuous outcomes, we measured the arithmetic mean and standard deviation (SD), and reported the mean difference (MD) with 95% confidence interval (CI) between groups. For dichotomous outcomes, we estimated and compared the risk ratio (RR) with 95% CIs between groups. For time-to-event data, we planned to calculate the survival time from the date of randomisation and to estimate and express the intervention effect as the hazard ratio (HR). We assessed the certainty of evidence using GRADE and created two summary of findings tables. MAIN RESULTS: We identified one new study (200 participants), for a total of four studies included in this update (422 participants). All participants had a diagnosis of advanced cancer. With the exception of 29 participants who had a haematological malignancy, all others were solid organ cancers. Two studies each compared MAH to placebo and standard care. There were too few included studies to evaluate different subgroups, such as type of participant, intervention, timing of intervention, and study site. We considered one study to be at high risk of performance and detection bias due to lack of blinding; otherwise, risk of bias was assessed as low or unclear. MAH compared with placebo Quality of life One study measured change in QoL at one week using Functional Assessment of Cancer Therapy - General (FACT-G) (scale from 0 to 108; higher score = better QoL). No data were available from the other study. We are uncertain whether MAH improves QoL (MD 4.10, 95% CI -1.63 to 9.83; 1 study, 93 participants, very low-certainty evidence). Survival One study reported on survival from study enrolment to last date of follow-up or death. We were unable to estimate HR. No data were available from the other study. We are uncertain whether MAH improves survival (1 study, 93 participants, very low-certainty evidence). Adverse events One study reported on intensity of adverse events at two days using a numeric rating scale (scale from 0 to 10; lower score = less toxicity). No data were available from the other study. We are uncertain whether MAH leads to adverse events (injection site pain: MD 0.35, 95% CI -1.19 to 1.89; injection site swelling MD -0.59, 95% CI -1.40 to 0.22; 1 study, 49 participants, very low-certainty evidence). MAH compared with standard care Quality of life No data were available for QoL. Survival One study measured survival from randomisation to last date of follow-up at 14 days or death. No data were available from the other study. We are uncertain whether MAH improves survival (HR 0.36, 95% CI 0.22 to 0.59; 1 study, 200 participants, very low-certainty evidence). Adverse events Two studies measured adverse events at follow-up (range 2 to 14 days). We are uncertain whether MAH leads to adverse events (RR 11.62, 95% CI 1.62 to 83.41; 2 studies, 242 participants, very low-certainty evidence). AUTHORS' CONCLUSIONS: Since the previous update of this review, we have found one new study. In adults receiving palliative care in the end stage of their illness, there remains insufficient evidence to determine whether MAH improves QoL or prolongs survival, compared with placebo or standard care. Given that all participants were inpatients with advanced cancer at end of life, our findings are not transferable to adults receiving palliative care in other settings, for non-cancer, dementia or neurodegenerative diseases, or for those with an extended prognosis. Clinicians will need to make decisions based on the perceived benefits and harms of MAH for each individual's circumstances, without the benefit of high-quality evidence to guide them.
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Affiliation(s)
| | - Alison Haywood
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Australia
- Mater Research Institute - The University of Queensland, Brisbane, Australia
| | - William Syrmis
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland, Brisbane, Australia
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Australia
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Nonogaki T, Maeda K, Shimizu A, Ueshima J, Nagano A, Kato R, Ishida Y, Yamanaka R, Yamanaka Y, Mori N. Nutrition provided during the final weeks to patients with non-gastrointestinal solid malignancies. Clin Nutr ESPEN 2023; 57:494-500. [PMID: 37739697 DOI: 10.1016/j.clnesp.2023.07.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/25/2023] [Accepted: 07/25/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND & AIMS Data regarding the delivery of nutrition and nutritional infusions to patients with terminal cancer remain limited; therefore, this real-world analysis investigated differences in nutrition delivery and infusion statuses for patients with terminal-stage cancers. METHODS Patients who had died following hospitalization for more than seven days due to neoplasms between April 2014 and December 2018 were identified using the medical claims database of Japan. Data regarding oral diets, enteral feeding, infusion volumes, and infusion energies were extracted. The maximum observation period was 28 days prior to patient death. RESULTS A total of 12,908 patients were included in our analysis. The proportion of patients without dietary or enteral nutrition increased closer to their dates of death. Observations were recorded at 28 (18.9%), 21 (20.9%), 14 (24.6%), 7 (33.0%), and 0 (80.2%) days prior to death. The infusion volumes given to the patients, as well as their energy contents, decreased near death (P-value for the trend <0.001). CONCLUSIONS Our study revealed the current status of nutritional therapy for patients with terminal cancer in Japan. The number of patients receiving only parenteral nutrition increased near death, while the amount of nutritional intake was low.
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Affiliation(s)
- Tomoyuki Nonogaki
- Department of Pharmacy, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Keisuke Maeda
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Nutrition Therapy Support Center, Aichi Medical University Hospital, Japan; Department of Geriatric Medicine, Hospital, National Center for Geriatrics and Gerontology, 7-430 Morioka, Obu, Aichi 474-8511, Japan.
| | - Akio Shimizu
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Health Science, Faculty of Health and Human Development, The University of Nagano, 8-49-7, Nagano, Japan
| | - Junko Ueshima
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nutritional Service, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa, Tokyo 141-8625, Japan
| | - Ayano Nagano
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nursing Care, Nishinomiya Kyoritsu Neurosurgical Hospital, 11-1 Imazuyamanaka-cho, Nishinomiya, Hyogo 663-821, Japan
| | - Ryoko Kato
- Department of Pharmacy, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Yuria Ishida
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nutrition, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Remi Yamanaka
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Dentistry and Oral Surgery, Aichi Medical University 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yosuke Yamanaka
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Dentistry and Oral Surgery, Aichi Medical University 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Naoharu Mori
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Nutrition Therapy Support Center, Aichi Medical University Hospital, Japan
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Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
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Friedrichsen M, Lythell C, Waldréus N, Jaarsma T, Ångström H, Milovanovic M, Karlsson M, Milberg A, Thulesius H, Hedman C, Schaller AS, Jaarsma P. Ethical challenges around thirst in end-of-life care -experiences of palliative care physicians. BMC Med Ethics 2023; 24:61. [PMID: 37559116 PMCID: PMC10413708 DOI: 10.1186/s12910-023-00943-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Thirst and dry mouth are common symptoms in terminally ill patients. In their day-to-day practice, palliative care physicians regularly encounter ethical dilemmas, especially regarding artificial hydration. Few studies have focused on thirst and the ethical dilemmas palliative care physicians encounter in relation to this, leading to a knowledge gap in this area. AIM The aim of this study was to explore palliative care physicians' experiences of ethical challenges in relation to thirst in terminally ill patients. METHODS A qualitative interview study with an inductive approach was conducted. Sixteen physicians working in four different specialised palliative care units and one geriatric care unit in different hospitals in Sweden were interviewed. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis. RESULTS When presented with an ethical challenge relating to thirst, physicians attempted to balance benefits and harms while emphasizing respect for the patient's autonomy. The ethical challenges in this study were: Starting, continuing or discontinuing drips; lack of evidence and traditions create doubt; and lack of interest and time may result in patient suffering. CONCLUSIONS All physicians in this study reported that "Starting, continuing or discontinuing drips" was the main ethical challenge they encountered, where some were so accustomed to the decision that they had a standard answer ready to offer patients and families. Physicians reported that drips were a symbol of thirst quenching, life and survival but were not necessary in end-of-life care. Others questioned the traditions regarding thirst and emphasised drips in particular.
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Affiliation(s)
- Maria Friedrichsen
- Palliative Education and Research Centre, Vrinnevi hospital, Norrköping, Sweden.
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Caroline Lythell
- Palliative Education and Research Centre, Vrinnevi hospital, Norrköping, Sweden
| | - Nana Waldréus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Helene Ångström
- Palliative Education and Research Centre, Vrinnevi hospital, Norrköping, Sweden
| | - Micha Milovanovic
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine, Vrinnevi hospital, Norrköping, Sweden
| | - Marit Karlsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Milberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hans Thulesius
- Department of Medicine and Optometry, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden and Region Kronoberg, Växjö, Sweden
| | - Christel Hedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- R & D Department, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Anne Söderlund Schaller
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Pier Jaarsma
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Pérez-Camargo DA, Allende-Pérez SR, Rivera-Franco MM, Urbalejo-Ceniceros VI, Sevilla-González MDLL, Arzate-Mireles CE, Copca-Mendoza ET. Clinical effects of hydration, supplementary vitamins, and trace elements during end-of-life care for cancer patients. NUTR HOSP 2023. [PMID: 37073755 DOI: 10.20960/nh.04446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Mónica M Rivera-Franco
- Department of Hematology and Oncology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
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Davies A, Barry C, Barclay S. What is the role of clinically assisted hydration in the last days of life? BMJ 2023; 380:e072116. [PMID: 36931630 DOI: 10.1136/bmj-2022-072116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Affiliation(s)
- Andrew Davies
- Trinity College Dublin, University College Dublin, and Our Lady's Hospice, Dublin, Republic of Ireland; University of Surrey, Guildford, UK
| | - Caroline Barry
- Norfolk and Norwich University Hospitals, and University of East Anglia, Norwich, UK
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Ordoñez Torres K, Walter Araya A. ¿Es proporcionado suspender la nutrición e hidratación artificial en pacientes con pronóstico incierto? REVISTA LATINOAMERICANA DE BIOÉTICA 2022. [DOI: 10.18359/rlbi.5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Para llevar a cabo esta investigación, se revisó la literatura sobre el caso de Terri Schiavo, paciente que se encontraba en estado vegetativo persistente y quien falleció luego de dos semanas, después de que se le suspendiera su alimentación e hidratación; se validó su diagnóstico y se indagó si fue una paciente terminal, así como también se verificó la evidencia disponible, en relación con la hidratación y nutrición artificial en este tipo de pacientes, para determinar la concordancia de estas medidas. Esta información fue analizada desde la perspectiva nutricional y bioética; en la búsqueda bibliográfica se consultaron las bases de datos Scopus, Scielo y PubMed, con los criterios de búsqueda nutrición e hidratación artificial en pacientes terminales y de pronóstico incierto. Estos hallazgos fueron analizados con el modelo de proporcionalidad terapéutica de Calipari. Por lo anterior, se determinó que la nutrición e hidratación artificial configuraban tratamientos de carácter obligatorio u optativo para Terri. Sin embargo, pese a que no existe información concluyente sobre la nutrición e hidratación artificial en pacientes terminales, ni de pronóstico incierto, se recomienda la evaluación caso a caso de parte del equipo médico, para determinar la proporcionalidad de estos procedimientos en conjunto con el paciente y su familia. Cabe resaltar que son necesarios más estudios para proporcionar mejor evidencia que permita contar con elementos objetivos para una mejor toma de decisiones.
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Davies A, Waghorn M, Roberts M, Gage H, Skene SS. Clinically assisted hydration in patients in the last days of life ('CHELsea II' trial): a cluster randomised trial. BMJ Open 2022; 12:e068846. [PMID: 36418131 PMCID: PMC9684991 DOI: 10.1136/bmjopen-2022-068846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Davies
- Trinity College Dublin, Dublin, Ireland
- University College Dublin, Dublin, Ireland
- Our Lady's Hospice & Care Services, Dublin, Ireland
- University of Surrey, Guildford, UK
| | - Melanie Waghorn
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Megan Roberts
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
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11
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Cleary N, Gouldthorpe C, Power J, Davies A. Correspondence re MASCC evidence-based recommendations for the management of malignant bowel obstruction. Support Care Cancer 2022; 30:7823-7824. [PMID: 35581356 DOI: 10.1007/s00520-022-07147-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/13/2022] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | - Andrew Davies
- Trinity College Dublin, University College Dublin, Our Lady's Hospice, Dublin, Ireland.
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12
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Agar MR, Chang S, Amgarth-Duff I, Garcia MV, Hunt J, Phillips JL, Sinnarajah A, Fainsinger R. Investigating the benefits and harms of hypodermoclysis of patients in palliative care: A consecutive cohort study. Palliat Med 2022; 36:830-840. [PMID: 35531661 DOI: 10.1177/02692163221082245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative populations are at risk for dehydration which can cause discomfort, distress and cognitive symptoms. Subcutaneous hydration ('hypodermoclysis') has been used as an alternative administration route to the more invasive intravenous route, but research is lacking on its net clinical effects (harms and benefits) for palliative populations, particularly in real world settings. AIM To quantify prospectively the net clinical effects of hypodermoclysis in palliative patients with advanced disease who required supplementary fluids. DESIGN Multisite, multinational consecutive cohort study. SETTING/PARTICIPANTS Patients receiving hypodermoclysis in an inpatient palliative care setting. RESULTS Twenty sites contributed data for 99 patients, of which 88 had complete benefits and harms data. The most common primary target symptom for infusion was generalised weakness (18.2%), and the most common non-symptom indication was supplemental hydration (31.8%). Benefits were experienced in 33% of patients in their primary target symptom, and in any symptom in 56.8%. Harms were experienced in 38.7% of patients (42% at Grade 1). Benefits increased with higher performance status, while harms were more frequent in patients with lower performance status (Australia-modified Karnofsky performance status ⩽40). Patients in the terminal phase of their illness experienced the least benefit (15.4% in any indication only) and had more frequent harms (38%). CONCLUSIONS Hypodermoclysis may improve certain symptoms in patients in palliative care but frequency of harms and benefits may differ at certain timepoints in the illness trajectory. Further research is needed to better delineate which patients will derive the most net clinical benefit from hypodermoclysis.
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Affiliation(s)
- Meera R Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Sungwon Chang
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Ingrid Amgarth-Duff
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Maja V Garcia
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame Australia, Sydney, Australia
| | - Jane Hunt
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia.,Queensland University of Technology, Brisbane, Australia
| | - Aynharan Sinnarajah
- Department of Medicine, Lakeridge Health, Oshawa, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Robin Fainsinger
- Division of Palliative Care Medicine, University of Alberta, Edmonton, AB, Canada
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13
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Ieda S, Miyamoto T, Hosomi K, Takegami M, Kawabata A. Identification of Remaining Life Expectancy Less Than Two Weeks by C-Reactive Protein/Albumin Ratio, Prognostic Nutritional Index, Fibrosis-4 Index, and Albumin-Bilirubin Score in Terminal Cancer Patients. J Palliat Med 2021; 25:570-576. [PMID: 34612718 DOI: 10.1089/jpm.2021.0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Accurate prognosis in terminal cancer patients is useful to improve their quality of life and also to decide the cessation of fluid administration. Nonetheless, few prognostic indicators are available for prediction of such a short-term life expectancy. Objectives: The present study aimed at evaluating the efficacy of C-reactive protein (CRP)/albumin (CRP/Alb) ratio, prognostic nutritional index (PNI), fibrosis-4 (FIB-4) index, and albumin-bilirubin (ALBI) score in identifying terminal cancer patients who have a life expectancy less than two weeks. Design: Retrospective study. Setting/Subjects: Of 483 patients who died between April 2019 and March 2020 at a single center in Japan, 102 who met the inclusion criteria were enrolled in this study. Measurements: CRP/Alb, PNI, FIB-4, and ALBI were calculated from the laboratory data collected 1-13, 14-27, 28-83, and 168-365 days before death and subjected to statistical analyses. Results: CRP/Alb, PNI, FIB-4, and ALBI values were significantly associated with the time before death during terminal 365 days. CRP/Alb ≥4.4, PNI <30, FIB-4 ≥ 9.4, and ALBI ≥ -1.26 were significantly associated with the transition from the first half to the second half of terminal four weeks. Of those prognostic indicators, three and four combinations provided significantly reliable estimation of a life expectancy less than two weeks. Conclusions: CRP/Alb, PNI, FIB-4, ALBI, and their combinations are considered to help identify cancer patients who have a life expectancy less than two weeks, which is useful to make appropriate end-stage treatment decisions, for example, cessation of artificial hydration therapy.
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Affiliation(s)
- Shoko Ieda
- Department of Pharmacy, Kindai University Hospital, Osakasayama, Japan
| | - Tomoyoshi Miyamoto
- Faculty of Pharmacy, Kindai University, Higashi-Osaka, Japan.,Department of Pharmacy, Seichokai Fuchu Hospital, Izumi, Japan
| | - Kouichi Hosomi
- Faculty of Pharmacy, Kindai University, Higashi-Osaka, Japan
| | - Manabu Takegami
- Department of Pharmacy, Kindai University Hospital, Osakasayama, Japan
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14
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Bennet D, Khorsandian Y, Pelusi J, Mirabella A, Pirrotte P, Zenhausern F. Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population. Clin Transl Med 2021; 11:e461. [PMID: 34185420 PMCID: PMC8214861 DOI: 10.1002/ctm2.461] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/11/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.
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Affiliation(s)
- Devasier Bennet
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | - Yasaman Khorsandian
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | | | | | - Patrick Pirrotte
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
| | - Frederic Zenhausern
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
- HonorHealth Research InstituteScottsdaleUSA
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
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15
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Muscaritoli M, Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Oldervoll L, Ravasco P, Solheim TS, Strasser F, de van der Schueren M, Preiser JC, Bischoff SC. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr 2021; 40:2898-2913. [PMID: 33946039 DOI: 10.1016/j.clnu.2021.02.005] [Citation(s) in RCA: 390] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 01/23/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients. METHODS ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer. RESULTS A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine University La Sapienza, Rome, Italy.
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Patrick Bachmann
- Centre Regional de Lutte Contre le Cancer Leon Berard, Lyon, France
| | - Vickie Baracos
- Department of Oncology, University of Alberta, Edmonton, Canada
| | | | - Hartmut Bertz
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Elisabeth Hütterer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | | | - Stein Kaasa
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Zeljko Krznaric
- University Hospital Center and School of Medicine, Zagreb, Croatia
| | - Barry Laird
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Alessandro Laviano
- Department of Translational and Precision Medicine University La Sapienza, Rome, Italy
| | | | - Line Oldervoll
- Center for Crisis Psychology, University of Bergen, Norway/Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Paula Ravasco
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Tora S Solheim
- Cancer Clinic, St.Olavs Hospital, Trondheim University Hospital, Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Norway
| | - Florian Strasser
- Oncological Palliative Medicine, Clinic Oncology/Hematology, Department Internal Medicine and Palliative Center, Cantonal Hospital St. Gallen, Switzerland
| | - Marian de van der Schueren
- HAN University of Applied Sciences, Nijmegen, the Netherlands; Wageningen University and Research, Wageningen, the Netherlands
| | | | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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16
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Kingdon A, Spathis A, Brodrick R, Clarke G, Kuhn I, Barclay S. What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis. BMJ Support Palliat Care 2020; 11:68-74. [PMID: 33046445 PMCID: PMC7907559 DOI: 10.1136/bmjspcare-2020-002600] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Arjun Kingdon
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Anna Spathis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Robert Brodrick
- Community Specialist Palliative Care Team, Arthur Rank Hospice Charity, Cambridge, UK.,Department of Palliative Medicine, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gemma Clarke
- Academic Unit of Palliative Care, University of Leeds School of Medicine, Leeds, UK
| | - Isla Kuhn
- Medical Library, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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17
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Broadhurst D, Cooke M, Sriram D, Gray B. Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews. PLoS One 2020; 15:e0237572. [PMID: 32833979 PMCID: PMC7446806 DOI: 10.1371/journal.pone.0237572] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 07/29/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality. INTRODUCTION Peripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route. METHODS Systematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation. RESULTS The search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery. CONCLUSION Subcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.
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Affiliation(s)
- Daphne Broadhurst
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- Infusion Excellence Consulting, Ottawa, Canada
| | - Marie Cooke
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
- School of Nursing and Midwifery, Nathan Campus, Griffith University, Queensland, Australia
| | - Deepa Sriram
- Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Queensland, Australia
| | - Brenda Gray
- Clinical Pharmacy Partners, Tampa, Florida, United States of America
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18
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Matsuda Y, Tanimukai H, Inoue S, Inada S, Sugano K, Hasuo H, Yoshimura M, Wada S, Dotani C, Adachi H, Okamoto Y, Takeuchi M, Fujisawa D, Kako J, Sasaki C, Kishi Y, Akizuki N, Inagaki M, Uchitomi Y, Matsushima E, Okuyama T. JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2020; 50:586-593. [PMID: 32215557 PMCID: PMC7202141 DOI: 10.1093/jjco/hyaa003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements. RESULTS This article provides a summary of the recommendations with rationales for each, as well as a short summary. CONCLUSIONS These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Hideaki Hasuo
- Department of Psychosomatic Medicine, Kansai Medical University, Hirakata, Japan
| | - Masafumi Yoshimura
- Department of Neuropsychiatry, Kansai Medical University, Moriguchi, Japan
| | - Saho Wada
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Yoshiaki Okamoto
- Department of Pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Mari Takeuchi
- Department of Palliative Care, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Division of Patient Safety, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Chiyuki Sasaki
- Nursing Department, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki 211-8533, Japan
| | - Nobuya Akizuki
- Department of Psycho-Oncology/Psychiatry, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo 693-8501, Japan
| | - Yosuke Uchitomi
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Tokyo 104-0045, Japan
| | - Eisuke Matsushima
- Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Toru Okuyama
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
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19
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Yokoyama T, Terawaki K, Minami K, Miyano K, Nonaka M, Uzu M, Kashiwase Y, Yanagihara K, Ueta Y, Uezono Y. Modulation of synaptic inputs in magnocellular neurones in a rat model of cancer cachexia. J Neuroendocrinol 2018; 30:e12630. [PMID: 29944778 DOI: 10.1111/jne.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/24/2018] [Indexed: 11/29/2022]
Abstract
In cancer cachexia, abnormal metabolism and neuroendocrine dysfunction cause anorexia, tissue damage and atrophy, which can in turn alter body fluid balance. Arginine vasopressin, which regulates fluid homeostasis, is secreted by magnocellular neurosecretory cells (MNCs) of the hypothalamic supraoptic nucleus. Arginine vasopressin secretion by MNCs is regulated by both excitatory and inhibitory synaptic activity, alterations in plasma osmolarity and various peptides, including angiotensin II. In the present study, we used whole-cell patch-clamp recordings of brain slices to determine whether hyperosmotic stimulation and/or angiotensin II potentiate excitatory synaptic input in a rat model of cancer cachexia, similar to their effects in normal (control) rats. Hyperosmotic (15 and 60 mmol L-1 mannitol) stimulation and angiotensin II (0.1 μmol L-1 ) increased the frequency, but not the amplitude, of miniature excitatory postsynaptic currents in normal rats; in model rats, both effects were significantly attenuated. These results suggest that cancer cachexia alters supraoptic MNC sensitivity to osmotic and angiotensin II stimulation.
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Affiliation(s)
- Toru Yokoyama
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
- Department of Physiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kiyoshi Terawaki
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
- Tsumura Research Laboratories, Tsumura & Co., Ibaraki, Japan
| | - Kouichiro Minami
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
- Department of Physiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Kanako Miyano
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
| | - Miki Nonaka
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
| | - Miaki Uzu
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
| | - Yohei Kashiwase
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
- Laboratory of Molecular Pathology and Metabolic Disease, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Kazuyoshi Yanagihara
- Division of Biomarker Discovery, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Yoichi Ueta
- Department of Physiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasuhito Uezono
- Cancer Pathophysiology Division, National Cancer Center Research Institute, Tokyo, Japan
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20
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Davies AN, Waghorn M, Webber K, Johnsen S, Mendis J, Boyle J. A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life. Palliat Med 2018; 32:733-743. [PMID: 29343167 DOI: 10.1177/0269216317741572] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine. AIM The aim of this feasibility study was to answer the question 'can a definitive (adequately powered) study be done?' DESIGN The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention 'A' (regular mouth care and usual other care) or intervention 'B' (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival. SETTING/PARTICIPANTS The study was conducted at 12 sites/'clusters' with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake. RESULTS The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as 'severe' or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1). CONCLUSION The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).
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Affiliation(s)
- Andrew N Davies
- 1 Royal Surrey County Hospital, Guildford, UK.,2 University of Surrey, Guildford, UK
| | | | - Katherine Webber
- 1 Royal Surrey County Hospital, Guildford, UK.,2 University of Surrey, Guildford, UK
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Canihuante J, Pérez P. Is parenteral hydration beneficial in terminally ill cancer patients? Medwave 2018; 18:e7150. [PMID: 29474350 DOI: 10.5867/medwave.2018.01.7149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 12/20/2017] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION It is common for terminally ill patients to have a reduced fluid intake, which often results in a need for more medical support. However, it is not clear if this measure has a real clinical impact. METHODS To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified four systematic reviews including 51 studies overall, from which three were randomized trials. We concluded the administration of parenteral hydration might make little or no difference in terms of survival and quality of life in terminally ill cancer patients, and that it is not clear whether it has any other benefit because the certainty of the evidence is very low.
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Affiliation(s)
- José Canihuante
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile
| | - Pedro Pérez
- Proyecto Epistemonikos, Santiago, Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. . Address: Centro Evidencia UC, Pontificia Universidad Católica de Chile, Centro de Innovación UC Anacleto Angelini, Avda. Vicuña Mackenna 4860, Macul, Santiago, Chile
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Caccialanza R, Constans T, Cotogni P, Zaloga GP, Pontes-Arruda A. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. JPEN J Parenter Enteral Nutr 2018; 42:296-307. [PMID: 29443395 DOI: 10.1177/0148607116676593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/04/2016] [Indexed: 11/17/2022]
Abstract
Subcutaneous infusion, or hypodermoclysis, is a technique whereby fluids are infused into the subcutaneous space via small-gauge needles that are typically inserted into the thighs, abdomen, back, or arms. In this review, we provide an overview of the technique, summarize findings from studies that have examined the use of subcutaneous infusion of fluids for hydration or nutrition, and describe the indications, advantages, and disadvantages of subcutaneous infusion. Taken together, the available evidence suggests that, when indicated, subcutaneous infusion can be effective for administering fluids for hydration or nutrition, with minimal complications, and has similar effectiveness and safety to the intravenous route. Of note, subcutaneous infusion offers several advantages over intravenous infusion, including ease of application, low cost, and the lack of potential serious complications, particularly infections. Subcutaneous infusion may be particularly suited for patients with mild to moderate dehydration or malnutrition when oral/enteral intake is insufficient; when placement of an intravenous catheter is not possible, tolerated, or desirable; at risk of dehydration when oral intake is not tolerated; as a bridging technique in case of difficult intravenous access or catheter-related bloodstream infection while infection control treatment is being attempted; and in multiple settings (eg, emergency department, hospital, outpatient clinic, nursing home, long-term care, hospice, and home).
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Affiliation(s)
- Riccardo Caccialanza
- Servizio di Dietetica e Nutrizione Clinica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thierry Constans
- Service de Médecine Gériatrique, Centre Hospitalier Régional Universitaire and Université François Rabelais, Tours, France
| | - Paolo Cotogni
- Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
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Abstract
There is a paucity of data on whether interventions in individual palliative care units are evidence-based. Thirteen years ago an initial study evaluated the evidence base of interventions in palliative care. Using similar methodology in the present study, we evaluated the evidence for interventions performed in an inpatient palliative care setting, looking at level of evidence as well as quality and outcome of evidence. More than half of all the interventions (47 interventions, 59 percent) we looked at in a Brisbane, Australia, inpatient palliative care setting were based on a high level of evidence in the form of systematic reviews of randomized controlled trials (level I or level II). There were only a few interventions (10 percent) for which no evidence could be retrieved. Our results show that the evidence base for interventions in palliative care continues to evolve, but that there are still areas for which further high-quality studies are needed.
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Affiliation(s)
- Korana Kindl
- Department of Palliative Care, St. Vincent's Private Hospital, Brisbane, Queensland, Australia
| | - Phillip Good
- Mater Research Institute-University of Queensland; Department of Palliative and Supportive Care, Mater Health Services; and Department of Palliative Care, St. Vincent's Private Hospital, 411 Main Street, Kangaroo Point, Brisbane, Queensland, Australia 4169
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Abstract
Initiation or continuation of artificial hydration (AH) at the end of life requires unique considerations. A combination of ethical precedents and medical literature may provide clinical guidance on how to use AH at the end of life. The purpose of this review is to describe the ethical framework for and review current literature relating to the indications, benefits, and risks of AH at the end of life. Provider, patient, and family perspectives will also be discussed.
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Affiliation(s)
- Alexandria J Bear
- 1 Department of Medicine, Division of Palliative Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Elizabeth A Bukowy
- 2 Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jayshil J Patel
- 3 Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Forbat L, Kunicki N, Chapman M, Lovell C. How and why are subcutaneous fluids administered in an advanced illness population: a systematic review. J Clin Nurs 2017; 26:1204-1216. [PMID: 27982484 DOI: 10.1111/jocn.13683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To identify the mechanisms of subcutaneous fluid administration in advanced illness. BACKGROUND Hydration at end of life is a fundamental issue in quality care internationally. Decision-making regarding the provision of artificial hydration in advanced illness is complicated by a paucity of evidence-based guidance. Despite considerable attention given to the topic including two recent Cochrane reviews, there has been no focus in systematically identifying papers that report the mechanisms for delivering hydration subcutaneously. Consequently, there is a need to produce guidance on the site, mode, volume and rate of infusion, based on empirical evidence. DESIGN Systematic review of papers reporting empirical research data. METHODS Key databases (CENTRAL, Medline, EMBASE, Web of Science, CINAHL) were searched in September 2015, with no date limitations. Inclusion criteria focused on hypodermoclysis in adults within an advanced illness population. Selected studies were reviewed for quality and a risk-of-bias assessment was conducted for the included studies. RESULTS Fourteen papers were included in the analysis; most (n = 8) were conducted in hospices with others (n = 6) in long-stay units with a population affected by chronic conditions associated with ageing. Studies were of moderate or high quality. The site and mode of infusion were not well described in these papers, and rates of infusion varied widely allowing for little clear consensus to guide clinical practice in the administration of subcutaneous fluids. CONCLUSIONS Studies under-report the mechanisms by which artificial hydration is provided, creating a paucity of evidence-based guidance by which to practice. There is a need for evidence generated from nonmalignant populations to ensure applicability to the large number of people with other advanced illness. RELEVANCE TO CLINICAL PRACTICE In the absence of sufficiently powered robust evidence, the mode of delivery of artificial hydration at end of life remains in the gloaming between evidence and unfounded habit.
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Affiliation(s)
- Liz Forbat
- Centre of Palliative Care Research, Calvary Health Care and Australian Catholic University, Canberra, ACT, Australia
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Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Fearon K, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Muscaritoli M, Oldervoll L, Ravasco P, Solheim T, Strasser F, de van der Schueren M, Preiser JC. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017. [DOI: 10.1016/j.clnu.2016.07.015 10.1016/j.clnu.2016.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nwosu AC, Mayland CR, Mason S, Cox TF, Varro A, Ellershaw J. The Association of Hydration Status with Physical Signs, Symptoms and Survival in Advanced Cancer-The Use of Bioelectrical Impedance Vector Analysis (BIVA) Technology to Evaluate Fluid Volume in Palliative Care: An Observational Study. PLoS One 2016; 11:e0163114. [PMID: 27673684 PMCID: PMC5038956 DOI: 10.1371/journal.pone.0163114] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 09/04/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hydration in advanced cancer is a controversial area; however, current hydration assessments methods are poorly developed. Bioelectrical impedance vector analysis (BIVA) is an accurate hydration tool; however its application in advanced cancer has not been explored. This study used BIVA to evaluate hydration status in advanced cancer to examine the association of fluid status with symptoms, physical signs, renal biochemical measures and survival. MATERIALS AND METHODS An observational study of 90 adults with advanced cancer receiving care in a UK specialist palliative care inpatient unit was conducted. Hydration status was assessed using BIVA in addition to assessments of symptoms, physical signs, performance status, renal biochemical measures, oral fluid intake and medications. The association of clinical variables with hydration was evaluated using regression analysis. A survival analysis was conducted to examine the influence of hydration status and renal failure. RESULTS The hydration status of participants was normal in 43 (47.8%), 'more hydrated' in 37 (41.1%) and 'less hydrated' in 10 (11.1%). Lower hydration was associated with increased symptom intensity (Beta = -0.29, p = 0.04) and higher scores for physical signs associated with dehydration (Beta = 10.94, p = 0.02). Higher hydration was associated with oedema (Beta = 2.55, p<0.001). Median survival was statistically significantly shorter in 'less hydrated' patients (44 vs. 68 days; p = 0.049) and in pre-renal failure (44 vs. 100 days; p = 0.003). CONCLUSIONS In advanced cancer, hydration status was associated with clinical signs and symptoms. Hydration status and pre-renal failure were independent predictors of survival. Further studies can establish the utility of BIVA as a standardised hydration assessment tool and explore its potential research application, in order to inform the clinical management of fluid balance in patients with advanced cancer.
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Affiliation(s)
- Amara Callistus Nwosu
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Catriona R. Mayland
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Stephen Mason
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Trevor F. Cox
- Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, United Kingdom
| | - Andrea Varro
- School of Physiological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - John Ellershaw
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
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Miyashita M, Morita T, Shima Y, Kimura R, Takahashi M, Adachi I. Physician and Nurse Attitudes Toward Artificial Hydration for Terminally Ill Cancer Patients in Japan: Results of 2 Nationwide Surveys. Am J Hosp Palliat Care 2016; 24:383-9. [PMID: 17601834 DOI: 10.1177/1049909107300552] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study investigated physician and nurse attitudes toward artificial hydration in terminally ill cancer patients and compared differences in attitudes between these 2 professions and among clinical settings in Japan. The response rate was 53% (584/1123) for physicians and 79% for nurses (3328/4210). More physicians answered that artificial hydration alleviates the sensation of thirst. More palliative care unit physicians and nurses answered that withholding artificial hydration alleviated several physical symptoms. Oncologists answered that artificial hydration alleviated the sensation of thirst and fatigue. Discussion among patient-centered teams and individualized decision making are important. Because the differences identified here are attributable to differences in knowledge of artificial hydration for terminal cancer patients, oncologists should place greater emphasis on the opinion of palliative care specialists. Medical practitioners caring for terminal cancer patients should consider a broader range of views on hydration therapy, with a focus on effective hydration techniques and alternative interventions.
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Affiliation(s)
- Mitsunori Miyashita
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo.
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Zehm A, Mullin J, Zhang H. Thirst in Palliative Care #313. J Palliat Med 2016; 19:1009-10. [DOI: 10.1089/jpm.2016.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Higashiguchi T, Ikegaki J, Sobue K, Tamura Y, Nakajima N, Futamura A, Miyashita M, Mori N, Inui A, Ohta K, Hosokawa T. Guidelines for parenteral fluid management for terminal cancer patients. Jpn J Clin Oncol 2016; 46:986-992. [DOI: 10.1093/jjco/hyw105] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/11/2016] [Accepted: 07/04/2016] [Indexed: 11/14/2022] Open
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Abstract
Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Nakajima N. Characteristics of Oral Problems and Effects of Oral Care in Terminally Ill Patients With Cancer. Am J Hosp Palliat Care 2016; 34:430-434. [PMID: 26903536 DOI: 10.1177/1049909116633063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Various distresses appear in the terminal stage of cancer. Oral problems including dry mouth, stomatitis and candidiasis are one of the important problems which should be resolved. The purpose of this study was to investigate oral problems in this stage and improvement of dry mouth by oral care. METHODS The study subjects were consecutive terminally ill cancer patients admitted over the past 2 years. Patients were divided based on the status of oral food intake into good oral food intake group (≥30%) and poor oral food intake group. The following 3 items were retrospectively investigated: 1) The incidences of these oral problems, 2) Severity of dry mouth and complication with other oral problems, 3) Improvement of dry mouth using standard oral care by nursing staff and specialist oral care including dentists as needed. RESULTS There were 115 and 158 patients in good and poor oral intake groups, respectively. 1) The incidences of dry mouth, stomatitis, and candidiasis were significantly higher in poor oral intake group ( p < 0.001). 2) Severe cases of dry mouth (Grade-2&3) were noted in 20.0% and 64.8% in good and poor oral intake groups, respectively ( p < 0.0001). Candidiasis complication rate was significantly higher in poor oral intake group ( p = 0.0002). 3) The rate of dry mouth improvement by oral care was 100% in Grade-1, 86% in Grade-2 and 81% in Grade-3. CONCLUSION Oral problems occur in many of terminally ill cancer patients. Accurate diagnosis of oral problems and corresponding appropriate interventions are important for improving quality of end-of-life care.
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Affiliation(s)
- Nobuhisa Nakajima
- 1 Department of Palliative Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
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Murray-Brown F, Dorman S. Haloperidol for the treatment of nausea and vomiting in palliative care patients. Cochrane Database Syst Rev 2015; 2015:CD006271. [PMID: 26524474 PMCID: PMC6481565 DOI: 10.1002/14651858.cd006271.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nausea and vomiting are common symptoms in patients with terminal, incurable illnesses. Both nausea and vomiting can be distressing. Haloperidol is commonly prescribed to relieve these symptoms. This is an updated version of the original Cochrane review published in Issue 2, 2009, of Haloperidol for the treatment of nausea and vomiting in palliative care patients. OBJECTIVES To evaluate the efficacy and adverse events associated with the use of haloperidol for the treatment of nausea and vomiting in palliative care patients. SEARCH METHODS For this updated review, we performed updated searches of CENTRAL, EMBASE and MEDLINE in November 2013 and in November 2014. We searched controlled trials registers in March 2015 to identify any ongoing or unpublished trials. We imposed no language restrictions. For the original review, we performed database searching in August 2007, including CENTRAL, MEDLINE, EMBASE, CINAHL and AMED, using relevant search terms and synonyms. Handsearching complemented the electronic searches (using reference lists of included studies, relevant chapters and review articles) for the original review. SELECTION CRITERIA We considered randomised controlled trials (RCTs) of haloperidol for the treatment of nausea or vomiting, or both, in any setting, for inclusion. The studies had to be conducted with adults receiving palliative care or suffering from an incurable progressive medical condition. We excluded studies where nausea or vomiting, or both, were thought to be secondary to pregnancy or surgery. DATA COLLECTION AND ANALYSIS We imported records from each of the electronic databases into a bibliographic package and merged them into a core database where we inspected titles, keywords and abstracts for relevance. If it was not possible to accept or reject an abstract with certainty, we obtained the full text of the article for further evaluation. The two review authors independently assessed studies in accordance with the inclusion criteria. There were no differences in opinion between the authors with regard to the assessment of studies. MAIN RESULTS We considered 27 studies from the 2007 search. In this update we considered a further 38 studies from the 2013 search, and two in the 2014 search. We identified one RCT of moderate quality with low risk of bias overall which met the inclusion criteria for this update, comparing ABH (Ativan®, Benadryl®, Haldol®) gel, applied to the wrist, with placebo for the relief of nausea in 22 participants. ABH gel includes haloperidol as well as diphenhydramine and lorazepam. The gel was not significantly better than placebo in this small study; however haloperidol is reported not to be absorbed significantly when applied topically, therefore the trial does not address the issue of whether haloperidol is effective or well-tolerated when administered by other routes (e.g. by mouth, subcutaneously or intravenously). We identified one ongoing trial of haloperidol for the management of nausea and vomiting in patients with cancer, with initial results published in a conference abstract suggesting that haloperidol is effective for 65% of patients. The trial had not been fully published at the time of our review. A further trial has opened, comparing oral haloperidol with oral methotrimeprazine (levomepromazine) for patients with cancer and nausea unrelated to their treatment, which we aim to include in the next review update. AUTHORS' CONCLUSIONS Since the last version of this review, we found one new study for inclusion but the conclusion remains unchanged. There is incomplete evidence from published RCTs to determine the effectiveness of haloperidol for nausea and vomiting in palliative care. Other than the trial of ABH gel vs placebo, we did not identify any fully published RCTs exploring the effectiveness of haloperidol for nausea and vomiting in palliative care patients for this update, but two trials are underway.
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Affiliation(s)
- Fay Murray-Brown
- Speciality Training Programme in Palliative Medicine, Peninsula Deanery, Devon, UK
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Davies A, Waghorn M, Boyle J, Gallagher A, Johnsen S. Alternative forms of hydration in patients with cancer in the last days of life: study protocol for a randomised controlled trial. Trials 2015; 16:464. [PMID: 26466809 PMCID: PMC4607172 DOI: 10.1186/s13063-015-0988-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
Background The provision of clinically assisted hydration at the end of life is one of the most contentious issues in medicine, and indeed within the general population. The reasons for contention include: a) the lack of evidence for or against; b) the disparate opinions of healthcare professionals; and c) the generally positive opinions of patients and their carers about clinically assisted hydration. Methods/design The study is a cluster randomised trial to assess the feasibility of conducting an adequately powered, randomised controlled trial of clinically assisted hydration in patients with cancer in the last days of life. Twelve sites, four National Health Service (NHS) hospitals and eight NHS/voluntary sector hospices in the United Kingdom, will be randomised to give either standard intervention A: continuance of oral intake and regular mouth care, or standard intervention B: continuance of oral intake, regular mouth care and clinically assisted hydration. Patients will be included if they: i) have a diagnosis of cancer; ii) are aged ≥ 18 yr; iii) have an estimated prognosis of ≤ 1 week and iv) are unable to maintain sufficient oral intake (1 L per day, measured/estimated); and v) are able to give informed consent. Patients will be excluded if they have contra-indications to receiving clinically assisted hydration. The primary endpoint of interest is the frequency of hyperactive delirium (‘terminal agitation‘), and this will be assessed using the Modified Richmond Agitation and Sedation Scale (administered every four hours). Other data to be collected include the frequency of pain, respiratory secretions (‘death rattle‘), dyspnoea, nausea and vomiting, adverse effects to clinically assisted hydration and overall survival. In addition, data will be collected on the use of anti-psychotic drugs, sedative drugs, analgesics, anti-secretory drugs and other end-of-life medication. The study has obtained full ethical approval. Discussion A randomised controlled trial of clinically assisted hydration in end-of-life care is urgently required. This feasibility study will allow methodological and ethical issues to be understood and addressed to ensure that a robust, adequately powered, randomised controlled trial is designed. Trial registration ClinicalTrials.gov NCT02344927 (registered 4 June 2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0988-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew Davies
- Royal Surrey County Hospital, Guildford, Surrey, GU2 7XX, UK.
| | - Melanie Waghorn
- Royal Surrey County Hospital, Guildford, Surrey, GU2 7XX, UK.
| | - Julia Boyle
- Surrey CTU, Surrey Clinical Research Centre, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Egerton Road, Guildford, Surrey, GU2 7XH, UK.
| | - Ann Gallagher
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, GU2 5XH, UK.
| | - Sigurd Johnsen
- Surrey CTU, Surrey Clinical Research Centre, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Egerton Road, Guildford, Surrey, GU2 7XH, UK.
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Nowarska A. Clinically assisted hydration and the Liverpool Care Pathway: Catholic ethics and clinical evidence. JOURNAL OF MEDICAL ETHICS 2015; 41:645-649. [PMID: 25034970 DOI: 10.1136/medethics-2013-101533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 06/27/2014] [Indexed: 06/03/2023]
Abstract
The Liverpool Care Pathway for the Dying Patient (LCP), a framework introduced for providing comfortable care at the last stage of life, has recently become highly contentious. Among the most serious allegations levelled against it, has been that the LCP may be used as a covert form of euthanasia by withdrawal of clinically assisted hydration (CAH). This concern has been raised, in particular by a number of Catholic medical professionals, who have asserted that the LCP is incompatible with Catholic ethics. This paper examines the key Catholic ethical principles relevant to treatment and care towards the end of life (the sanctity/inviolability of life principle, the distinction between ordinary and extraordinary means). Relevant current clinical evidence regarding CAH in relation to terminal thirst, dehydration, prolongation of life and possible negative impacts on the dying is also scrutinised. It is argued that for some patients at the very end of life it may be permissible and even desirable to withhold or withdraw it. Thus, as administration of CAH may become extraordinary, forgoing it in some situations is fully compatible with Catholic ethics. The article therefore concludes that the stance of the LCP in respect of provision of CAH is fully in alignment with Catholic teaching.
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Indications and practice of artificial hydration for terminally ill cancer patients. Curr Opin Support Palliat Care 2014; 8:358-63. [DOI: 10.1097/spc.0000000000000089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ishiki H, Iwase S, Gyoda Y, Kanai Y, Ariyoshi K, Miyaji T, Tahara Y, Kawaguchi T, Chinzei M, Yamaguchi T. Oral Nutritional Support Can Shorten the Duration of Parenteral Hydration in End-of-Life Cancer Patients: A Randomized Controlled Trial. Nutr Cancer 2014; 67:105-11. [DOI: 10.1080/01635581.2015.976312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sigurdardottir KR, Oldervoll L, Hjermstad MJ, Kaasa S, Knudsen AK, Løhre ET, Loge JH, Haugen DF. How are palliative care cancer populations characterized in randomized controlled trials? A literature review. J Pain Symptom Manage 2014; 47:906-914.e17. [PMID: 24018205 DOI: 10.1016/j.jpainsymman.2013.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 06/14/2013] [Indexed: 02/08/2023]
Abstract
CONTEXT The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research. OBJECTIVES To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs). METHODS The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles. RESULTS The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported. CONCLUSION A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.
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Affiliation(s)
- Katrin Ruth Sigurdardottir
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital, Bergen, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.
| | - Line Oldervoll
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Røros Rehabilitation Centre, Røros, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre for Excellence in Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Torbjørn Løhre
- Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jon Håvard Loge
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; National Resource Centre for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
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Good P, Richard R, Syrmis W, Jenkins‐Marsh S, Stephens J. Medically assisted hydration for adult palliative care patients. Cochrane Database Syst Rev 2014; 2014:CD006273. [PMID: 24760678 PMCID: PMC8988261 DOI: 10.1002/14651858.cd006273.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Many palliative care patients have reduced oral intake during their illness. The management of this can include the provision of medically assisted hydration with the aim of prolonging the life of a patient, improving their quality of life, or both. This is an updated version of the original Cochrane review published in Issue 2, 2008, and updated in February 2011. OBJECTIVES To determine the effect of medically assisted hydration in palliative care patients on their quality and length of life. SEARCH METHODS We identified studies by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible studies, key textbooks and previous systematic reviews. The date of the latest search conducted on CENTRAL, MEDLINE and EMBASE was March 2014. SELECTION CRITERIA All relevant randomised controlled trials (RCTs) or prospective controlled studies of medically assisted hydration in palliative care patients. DATA COLLECTION AND ANALYSIS We identified six relevant studies for this update. These included three RCTs (222 participants), and three prospective controlled trials (360 participants). Two review authors independently assessed the studies for quality and validity. The small number of studies and the heterogeneity of the data meant that a quantitative analysis was not possible, so we included a description of the main findings. MAIN RESULTS One study found that sedation and myoclonus (involuntary contractions of muscles) scores were improved more in the intervention group. Another study found that dehydration was significantly higher in the non-hydration group, but that some fluid retention symptoms (pleural effusion, peripheral oedema and ascites) were significantly higher in the hydration group. The other four studies (including the three RCTs) did not show significant differences in outcomes between the two groups. The only study that had survival as an outcome found no difference in survival between the hydration and control arms. AUTHORS' CONCLUSIONS Since the last version of this review, we found one new study. The studies published do not show a significant benefit in the use of medically assisted hydration in palliative care patients; however, there are insufficient good-quality studies to inform definitive recommendations for practice with regard to the use of medically assisted hydration in palliative care patients.
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Affiliation(s)
- Phillip Good
- Mater Research Institute – The University of Queensland411 Main StreetKangaroo PointBrisbaneQueenslandAustralia4169
| | - Russell Richard
- St Vincent’s Private Hospital411 Main StreetKangaroo PointBrisbaneQueenslandAustralia
| | - William Syrmis
- St Vincent’s Private Hospital411 Main StreetKangaroo PointBrisbaneQueenslandAustralia
| | - Sue Jenkins‐Marsh
- The Townsville HospitalTownsvilleAustralia
- St Vincent’s Private HospitalPalliative CareBrisbaneAustralia
| | - Jane Stephens
- St Vincent’s Private Hospital411 Main StreetKangaroo PointBrisbaneQueenslandAustralia
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Higgins I, van der Riet P, Sneesby L, Good P. Nutrition and hydration in dying patients: the perceptions of acute care nurses. J Clin Nurs 2013; 23:2609-17. [DOI: 10.1111/jocn.12478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Isabel Higgins
- Faculty of Health and Medicine; School of Nursing and Midwifery; University of Newcastle; Callaghan NSW Australia
- Centre for Practice Opportunity and Development; Hunter New England Local Health District; New Lambton NSW Australia
| | - Pamela van der Riet
- School of Nursing and Midwifery; University of Newcastle; Callaghan NSW Australia
| | - Ludmilla Sneesby
- Department of Palliative Care; Calvary Mater Newcastle Hospital; Waratah NSW Australia
| | - Phillip Good
- University of Newcastle; Callaghan NSW Australia
- University of Queensland; Brisbane Qld Australia
- St. Vincent's Hospital Brisbane; Brisbane Qld Australia
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Fritzson A, Tavelin B, Axelsson B. Association between parenteral fluids and symptoms in hospital end-of-life care: an observational study of 280 patients. BMJ Support Palliat Care 2013; 5:160-8. [DOI: 10.1136/bmjspcare-2013-000501] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 10/10/2013] [Indexed: 11/03/2022]
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Nwosu AC, Mayland CR, Mason SR, Khodabukus AF, Varro A, Ellershaw JE. Hydration in advanced cancer: can bioelectrical impedance analysis improve the evidence base? A systematic review of the literature. J Pain Symptom Manage 2013. [PMID: 23200189 DOI: 10.1016/j.jpainsymman.2012.08.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Decisions surrounding the administration of clinically assisted hydration to patients dying of cancer can be challenging because of the limited understanding of hydration in advanced cancer and a lack of evidence to guide health care professionals. Bioelectrical impedance analysis (BIA) has been used to assess hydration in various patient groupings, but evidence for its use in advanced cancer is limited. OBJECTIVES To critically appraise existing methods of hydration status assessment in advanced cancer and review the potential for BIA to assess hydration in advanced cancer. METHODS Searches were carried out in four electronic databases. A hand search of selected peer-reviewed journals and conference abstracts also was conducted. Studies reporting (de)hydration assessment (physical examination, biochemical measures, symptom assessment, and BIA) in patients with advanced cancer were included. RESULTS The results highlight how clinical examination and biochemical tests are standard methods of assessing hydration, but limitations exist with these methods in advanced cancer. Furthermore, there is disagreement over the evidence for some commonly associated symptoms with dehydration in cancer. Although there are limitations with using BIA alone to assess hydration in advanced cancer, analysis of BIA raw measurements through the method of bioelectrical impedance vector analysis may have a role in this population. CONCLUSION The benefits and burdens of providing clinically assisted hydration to patients dying of cancer are unclear. Bioelectrical impedance vector analysis shows promise as a hydration assessment tool but requires further study in advanced cancer. Innovative methodologies for research are required to add to the evidence base and ultimately improve the care for the dying.
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Affiliation(s)
- Amara Callistus Nwosu
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
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Boland E, Johnson M, Boland J. Artificial hydration in the terminally ill patient. Br J Hosp Med (Lond) 2013; 74:397-401. [DOI: 10.12968/hmed.2013.74.7.397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Oral fluid intake is often reduced in dying patients. This article outlines the clinical assessment of the likely net benefit of artificial hydration, and the evidence relating to its use.
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Affiliation(s)
- Elaine Boland
- Queen's Centre for Oncology and Haematology, Hull and East Yorkshire Hospitals NHS Trust, Cottingham
| | | | - Jason Boland
- Hull York Medical School, University of Hull, Hull HU6 7RX; Care Plus Group and St Andrew's Hospice, Grimsby, North East Lincolnshire
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Nakajima N, Hata Y, Kusumuto K. A Clinical Study on the Influence of Hydration Volume on the Signs of Terminally Ill Cancer Patients with Abdominal Malignancies. J Palliat Med 2013; 16:185-9. [DOI: 10.1089/jpm.2012.0233] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Yoshinobu Hata
- Sapporo Social Insurance General Hospital, Sapporo, Japan
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Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble J, Roosth J, Krauter S, Strickland C, Unger K, Palmer JL, Allo J, Frisbee-Hume S, Tarleton K. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2012; 31:111-8. [PMID: 23169523 DOI: 10.1200/jco.2012.44.6518] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE The vast majority of patients with cancer at the end of life receive parenteral hydration in hospitals and no hydration in hospice, with limited evidence supporting either practice. In this randomized controlled trial, we determined the effect of hydration on symptoms associated with dehydration, quality of life, and survival in patients with advanced cancer. PATIENTS AND METHODS We randomly assigned 129 patients with cancer from six hospices to receive parenteral hydration (normal saline 1 L per day) or placebo (normal saline 100 mL per day) daily over 4 hours. The primary outcome was change in the sum of four dehydration symptoms (fatigue, myoclonus, sedation and hallucinations, 0 = best and 40 = worst possible) between day 4 and baseline. Secondary outcomes included Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Nursing Delirium Screening Scale (NuDESC), Unified Myoclonus Rating Scale (UMRS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Dehydration Assessment Scale, creatinine, urea, and overall survival. Intention-to-treat analysis was conducted to examine the change by day 4 ± 2 and day 7 ± 2 between groups. RESULTS The hydration (n = 63) and placebo (n = 66) groups had similar baseline characteristics. We found no significant differences between the two groups for change in the sum of four dehydration symptoms (-3.3 v -2.8, P = .77), ESAS (all nonsignificant), MDAS (1 v 3.5, P = .084), NuDESC (0 v 0, P = .13), and UMRS (0 v 0, P = .54) by day 4. Results for day 7, including FACIT-F, were similar. Overall survival did not differ between the two groups (median, 21 v 15 days, P = .83). CONCLUSION Hydration at 1 L per day did not improve symptoms, quality of life, or survival compared with placebo.
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Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Is there a role for parenteral nutrition or hydration at the end of life? Curr Opin Support Palliat Care 2012; 6:365-70. [DOI: 10.1097/spc.0b013e328356ab4a] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yamaguchi T, Morita T, Shinjo T, Inoue S, Takigawa C, Aruga E, Tani K, Hara T, Tamura Y, Suga A, Adachi S, Katayama H, Osaka I, Saito Y, Nakajima N, Higashiguchi T, Hayashi T, Okabe T, Kohara H, Tamaki T, Chinone Y, Aragane H, Kanai Y, Tokura N, Yamaguchi T, Asada T, Uchitomi Y. Effect of parenteral hydration therapy based on the Japanese national clinical guideline on quality of life, discomfort, and symptom intensity in patients with advanced cancer. J Pain Symptom Manage 2012; 43:1001-12. [PMID: 22651946 DOI: 10.1016/j.jpainsymman.2011.06.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 06/08/2011] [Accepted: 06/14/2011] [Indexed: 11/29/2022]
Abstract
CONTEXT Although an evidence-based clinical guideline for parenteral hydration therapy was established in Japan, the efficacy of the guideline has not been assessed. OBJECTIVES Our purpose was to explore the effect of parenteral hydration therapy based on this clinical guideline on quality of life (QoL), discomfort, symptoms, and fluid retention signs in patients with advanced cancer. METHODS This multicenter, prospective, observational study included 161 patients with advanced abdominal cancer who received guideline-based hydration therapy. We evaluated the longitudinal changes of the global QoL (Item 30 of European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30); the Discomfort Scale; the intensity of seven physical symptoms; and the severity of fluid retention signs. We also evaluated patient satisfaction and the feeling of benefit from hydration one week after the study commenced, and bronchial secretions, hyperactive delirium, communication capacity, and agitation 48 hours before a patient's death. RESULTS The global QoL, the Discomfort Scale, and the intensities of all physical symptoms, except for vomiting and drowsiness, were stable throughout the study period. More than 80% of patients maintained all fluid retention signs. Patient global satisfaction was 76.4 (0-100) and feeling of benefit was 5.43 (range 0-7). CONCLUSION Guideline-based parenteral hydration therapy contributed to maintaining global QoL and provided satisfaction and a feeling of benefit without increasing discomfort and worsening symptoms and fluid retention signs in patients with advanced cancer.
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Affiliation(s)
- Takashi Yamaguchi
- Department of General Internal Medicine and Palliative Care Team, Teine Keijinkai Hospital, Sapporo, Japan.
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Raijmakers N, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, Voltz R, Ellershaw J, van der Heide A. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011; 22:1478-1486. [DOI: 10.1093/annonc/mdq620] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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