What`s Buzzing in the Literature?
What’s Buzzing in the Literature?
Focusing on Palliative Care
For many older adults living with chronic illness, palliative care often presents the most realistic and cost-effective way to reduce pain and improve quality of life. From diagnosis to end of life, palliative care supports patients and their families in many dimensions of healthcare, including emotional and spiritual needs. Although many patients and providers view palliative care as a last resort approach to care in long-term care facilities and hospice care, the principles of palliative care are becoming increasingly more accepted across care settings. The current literature base reflects the evolving understanding of the role of palliation in healthcare. Sean Marks, MD, specializes in palliative care as an assistant professor of medicine, division of hematology and oncology, at the Medical College of Wisconsin. Annals of Long-Term Care® asked Marks to identify articles that he considers to be the most significant contributions to the palliative care literature within the past year. His selections are given below, along with his rationale for including them.
Gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial.
Authors: Ryan NM, Birring SE, Gibson PG.
Published in: Lancet. 2012;380(9853):1583-1589.
Access at: www.ncbi.nlm.nih.gov/pubmed/22951084
Why this article is important: Cough is a common and at times distressing symptom for patients with serious illnesses. While often self-resolving, cough can become refractory and secondarily lead to dyspnea, sleep impairment, pain, and impaired communication. Similar to neuropathic pain, central sensitization may play a role in the pathophysiology of refractory cough. Thus, neuromodulatory therapeutics, such as gabapentin, may be especially targeted to treat refractory cough. In this randomized, double-blind, placebo-controlled trial of 62 adults with refractory cough, gabapentin was shown to have clinically meaningful improvement in cough-specific quality of life, cough severity, and cough frequency after 10 weeks of therapy. The number needed to treat was 3.6, and adverse effects of gabapentin were mostly nausea and vomiting .
Drug interactions in dying patients: a retrospective analysis of hospice inpatients in Germany.
Authors: Frechen S, Zoeller A, Ruberg K, Voltz R, Gaertner J.
Published in: Drug Saf. 2012;35(9):745-758.
Access at: www.ncbi.nlm.nih.gov/pubmed/22809376
Why this article is important: Drug-drug interactions (DDIs) have been studied in various clinical populations but not for imminently dying patients. In this retrospective analysis of medical records of German hospice patients, DDIs were screened by a federally approved electronic database among patients at the last 2 weeks of life. The results showed that 61% of the patients had potential for DDIs; the median number of drugs prescribed per patient was 10; and polypharmacy was the major predictor for DDIs. Drug categories most commonly involved in DDIs were antipsychotics, antiemetics, antidepressants, insulin, glucocorticoids, non-steroidal anti-inflammatory drugs, and cardiovascular drugs. Somewhat surprisingly, opioids or anxiolytics were not included as major troublesome agents. Based on these results, practitioners caring for imminently dying patients are encouraged to discontinue drugs aimed at primary or secondary prevention and to be particularly vigilant of polypharmacy.
Examining the effects of an outpatient palliative care consultation on symptom burden, depression, and quality of life in patients with symptomatic heart failure.
Authors: Evangelista LS, Lombardo D, Malik S, Ballard-Hernandez J, Motie M, Liao S.
Published in: J Card Fail. 2012;18(12):894-899.
Access at: www.ncbi.nlm.nih.gov/pubmed/23207076
Why this article is important: Outpatient palliative care clinics are growing in number and in the breadth of patients they see but have not been thoroughly evaluated for patients with heart failure. In this prospective case-control study, quality of life and the overall burden of physical symptoms and depression were assessed for 72 participants who received a palliative care outpatient consultation and compared with matched controls. Having a palliative care consultation was associated with significantly less fatigue, dyspnea, depression, pain, and nausea. Unfortunately, patients with an implantable cardioverter-defibrillator, ventricular assist device, or who had a life expectancy of less than 6 months were excluded from the study. Thus, more rigorously designed studies will be needed to confirm these findings among advanced heart failure patients.
Patient-physician communication about code status preferences: a randomized controlled trial.
Authors: Rhondali W, Perez-Cruz P, Hui D, et al.
Published in: Cancer. 2013;119(11):2067-2073.
Access at: www.ncbi.nlm.nih.gov/pubmed/23564395
Why this article is important: Code discussions are especially relevant in cancer care but there is no compelling evidence to suggest whether it is best for the physician to ask patients what they want or for physicians to make a clear recommendation with regard to code preferences. In this randomized controlled trial, the investigators created two videos showing a physician–patient code status discussion and measured what proportion of patients expressed a wish for a do-not-resuscitate (DNR) order after watching each video. They found that 74% chose DNR after the “question” video and 73% chose DNR after the “recommendation” video. Because the difference was statistically insignificant, the authors concluded that ending DNR discussions with a question or recommendation does not impact DNR choices. Although these results are intriguing and have been widely reported, it is important to note that these findings have limited generalizability because choosing DNR in a video vignette is not the same as choosing DNR for oneself.
Influence of hospice on nursing home residents with advanced dementia who received Medicare-skilled nursing facility care near the end of life.
Authors: Miller SC, Lima JC, Mitchell SL.
Published in: J Am Geriatr Soc. 2012;60(11):2035-2041.
Access at: www.ncbi.nlm.nih.gov/pubmed/23110337
Why this article is important: There are significant financial and system-based practice barriers that often prohibit patients from receiving skilled nursing facility (SNF) care concurrently with hospice care. In a retrospective cohort analysis, investigators assessed the outcomes of advanced dementia patients who died in a nursing home and received SNF care within 90 days of their death. They found that patients who received hospice either concurrently or after SNF care had a lower likelihood of dying in a hospital and received fewer medications, feeding tubes, injections, and intravenous fluids. Interestingly, however, concurrent hospice/SNF users had a higher likelihood of persistent pain. Because the analysis was retrospective, any causal associations are only speculative. Nevertheless, the findings suggest that the use of hospice care during or after SNF care has the potential to enhance the care patients with advanced dementia receive.
Older adults and forgoing cancer screening: “I think it would be strange.”
Authors: Torke AM, Schwartz PH, Holtz LR, Montz K, Sachs GA.
Published in: JAMA Intern Med. 2013;173(7):526-531.
Access at: www.ncbi.nlm.nih.gov/pubmed/23478883
Why this article is important: When patients age, or they experience a decline from a functional standpoint, or their underlying illness progresses to a point where survival may be limited, the risks of performing commonly recommended cancer screenings will outweigh the benefits. In a semi-structured, face-to-face interview of 33 adults older than 60 years, these investigators assessed how older adults feel about discontinuing screening. Many older adults viewed cancer screening as a habit rather than a medical decision; however, they considered cessation of cancer screening to be a major medical decision. Many reported never having a discussion about cessation of cancer screening and some expressed that they may become upset if the clinician recommended that screening be discontinued. Making recommendations based on the patient’s identified goals of care or making recommendations based on the balance of risks versus benefits were preferred communication strategies compared with recommendations based on expert or government panel guidelines.
Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial.
Authors: Smith EM, Pang H, Cirrincione C, et al; Alliance for Clinical Trials in Oncology.
Published in: JAMA. 2013;309(13):1359-1367.
Access at: www.ncbi.nlm.nih.gov/pubmed/23549581
Why this article is important: A substantial proportion of cancer patients develop chemotherapy-induced peripheral neuropathy, which can persist for months to years beyond chemotherapy completion and lead to significant debility. Unfortunately, there is poor medical evidence to support specific therapies. Duloxetine is a serotonin and norepinephrine dual reuptake inhibitor that has been shown to be an effective therapy for diabetic neuropathy. This study is the first well-designed randomized controlled trial to assess the effect of duloxetine for painful chemotherapy-induced peripheral neuropathy. It found that individuals who received duloxetine for 5 weeks experienced a mean decrease of 1.06 versus 0.34 for placebo on a validated 0 to 10 pain score. Furthermore, 59% of those who received duloxetine reported a meaningful decrease in their pain compared with only 38% of those who received placebo.
