Palliative sedation in a southern Appalachian community.

Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days).

Hospital charges for a community inpatient palliative care program.

Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of 65,795 dollars, and mean daily charges of 3,809 dollars. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of 3,117 dollars. These mean daily charges were 414 dollars less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test). The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of 4,105 dollars (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001). Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than 100,000 dollars per year, and estimated savings achieved using AIA follow-up charges were more than 1,801,930 dollars per year.

A palliative medicine program in a community setting: 12 points from the first 12 months.

This paper reports the first year's experience of a consultative, interdisciplinary, integrated palliative medicine program in a community hospital system. Prospective data collection was performed on 308 consecutive consultations. A computer database was developed and used to analyze demographics, reason for consultation, complexity of medical problems, current medications and allergies, physical suffering, spiritual concerns, personal and family concerns, consult recommendations, and mortality. In addition, data were collected on patient rating of the severity of physical symptoms, pain, spiritual suffering, and personal and family suffering; this data also was analyzed using the database. Cancer was the most frequent diagnosis (34 percent) and pain the most common reason for consultation (43 percent). Population medians were identified as follows: five (range, 1 to 10) acute medical problems; three (range, 1 to 10) chronic medical problems; and one (range, 0 to 10) medication allergy/intolerance. Patients were taking a median of 10 (range, 0 to 29) medications, including a median of two analgesics. Eighty percent could communicate concerning physical symptoms and had a median of two (range, 0 to 7) bothersome symptoms, with pain the most frequent. Fifty percent or fewer could rate physical suffering, pain, hope, spiritual suffering, or personal/family suffering using a 0 to 10 scale at consultation. Individual patient ratings provided over time for physical suffering, pain, hope, spiritual suffering, and personal/family suffering were available for less than 25 percent. A median of eight recommendations was made for each consultation, with medication changes suggested for 84 percent. For those known to have died, the median survival from time of consultation to death was 11 days.

Palliative medicine in a United States cancer center: a prospective study.

PURPOSE: (a) To report the medical complexity of cancer and noncancer patients receiving palliative medicine (PM) consultation at a tertiary medical center and (b) to describe the consult recommendations madefor this group. PATIENTS AND METHODS: Prospective data collection was performed on all consultations (cancer, n = 175; noncancer, n = 35) done by first author (JDC) as a PM fellow at the Cleveland Clinic Foundation between July 1998 and April 1999. A computer database was used to query for demographics, complexity of medical problems, current medications, mortality, symptoms, nursing problems, and consult recommendations. RESULTS: A median of three (range, 0-12) acute medical problems and three (range, 0-16) chronic medical problems were identified for each patient. Patients were taking a median of six medications (range, 0-20). They had a median of five symptoms (range, 0-13) with pain (73 percent) being most common, followed by weakness (40 percent) and shortness of breath (40 percent). Cancer patients were twice as likely to have more than five symptoms (48 percent versus 23 percent) (chi-square = 0.006). The most common nursing problems were ambulation or fall risk (15 percent) and skin integrity (11 percent). A median of five (range, 1-11) management recommendations were made as part of each consultation. These included medication changes in 81 percent, nonmedication changes in 53 percent, andfollow-up services in 100 percent. The median survivalfrom the time of consultation for the known dead was 29 days with 65 percent living more than 14 days. CONCLUSION: Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.

Practical guide to palliative sedation.

Terminally ill patients want assurance that their symptoms will be controlled as death approaches. Most patients can have a peaceful death with standard palliative care. Some patients approaching death, however, have refractory symptoms such as pain, dyspnea, nausea, and agitated delirium. Palliative sedation (PS), the use of medications to induce sedation in order to control refractory symptoms near death, is a therapeutic option for these patients. The reported frequency of PS use varies greatly, ranging from 5% to 52% of the terminally ill. One concern with PS is its effect on survival. Data suggest that PS does not lead to immediate death, with the median time to death after initiating PS being greater than 1 to 5 days. A number of medications have been used for PS, but midazolam is most commonly reported. PS is distinct from euthanasia because the intent of PS is relief from suffering without death as a required outcome.