Palliative Care Utilisation and Outcomes in Patients Admitted for Heart Failure in a Victorian Healthcare Service.

BACKGROUND: Heart failure (HF) has high mortality and healthcare utilisation. It has a complex and unpredictable trajectory, which is often interpreted as a barrier to guideline recommended early integration of palliative care (PC). In particular, lack of referral criteria and misconceptions around PC affect inpatient specialist PC referrals. AIMS: The main objective was to characterise the pattern and predictors of referral of HF patients to the specialist inpatient PC consultative service at our healthcare service. METHODS: A retrospective, single-centre cohort study was performed on consecutive patients admitted across the hospital with HF over a 12-month period (July 2019-June 2020). Mortality data were checked against state death registry data. RESULTS: The 502 patients admitted for HF were elderly (mean age 78±14 years), had high dependency (54% Australian-modified Karnofsky Performance Status (AKPS) 50-70, 29% AKPS 10-40), and high mortality (53% within median 32 months at death registry data linkage). Seven per cent (7%) were referred to inpatient specialist PC. AKPS 10-40 (62% of those referred vs 26% not referred, p<0.01), reliance on carers (65% vs 36%, p<0.01), and New York Heart Association (NYHA) class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but two or more admissions in the last 12 months for HF were not (16% vs 10%, p=0.21). Many PC domains, such as symptom burden, distress, and preferred care, were not adequately assessed. CONCLUSIONS: Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients.

Low Rates of Grief and Bereavement Support Pre- and Post-Death for Those Who Died Within 72 hours of Admission to a Quaternary Teaching Hospital.

Grief and bereavement support are crucial to good palliative and end-of-life care. Support models differ between and within services. In addition, while patient and family needs vary based on risk and resilience factors, acute or unexpected death is associated with complicated grief. Our study was a retrospective review of 159 patients who died within 72 hours of hospital admission. We found a high proportion of unexpected and traumatic deaths and low grief and bereavement support rates. Further work is needed to streamline policies to optimize patient and family-centred grief and bereavement support in the acute hospital setting.

Understanding end-of-life care in Australian hospitals.

ObjectiveTo explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study.MethodsIn total, 1693 in-hospital deaths, 356 in ICU, were reviewed, including patient demographics, advance care plans, life-sustaining treatments, recognition of dying by clinicians and evidence of the palliative approach to patient care.ResultsMost patients (n=1430, 84%) were aged ≥60 years, with a low percentage (n=208, 12%) having an end-of-life care plan on admission. Following admission, 82% (n=1391) of patients were recognised as dying, but the time between recognition of dying to death was short (ICU (staying 4-48h) median 0.34 days (first quartile (Q1), third quartile (Q3): 0.16, 0.72); Ward (staying more than 48h) median 2.1 days (Q1, Q3: 0.96, 4.3)). Although 41% (n=621) patients were referred for specialist palliative care, most referrals were within the last few days of life (2.3 days (0.88, 5.9)) and 62% of patients (n=1047) experienced active intervention in their final 48h.ConclusionsLate recognition of dying can expose patients to active interventions and minimises timely palliative care. To attain alignment to the National Consensus Statement to improve experiences of end-of-life care, a nationally coordinated approach is needed.What is known about the topic?The majority of Australian patient deaths occur in hospitals whose care needs to align to the Australian Commission on Safety and Quality in Health Care's National Consensus Statement, essential elements of safe and high-quality end-of-life care.What does this paper add?The largest Australian study of hospital deaths reveals only 12% of patients have existing advance care plans, recognition of death is predominantly within the last 48h of life, with 60% receiving investigations and interventions during this time with late symptom relief.What are the implications for practitioners?Given the poor alignment with the National Consensus Statement, a nationally coordinated approach would improve the patient experience of end-of-life care.

Bacteremia in the chronic spinal cord injury population: risk factors for mortality.

BACKGROUND: Individuals with spinal cord injury (SCI) have a lifelong increased risk of systemic infection, which may be associated with episodes of life-threatening bacteremia. Information concerning specific organisms causing bacteremia, the sites of primary infection, and clinical predictors for mortality are necessary to provide optimal treatment. METHODS: A retrospective review of positive blood cultures collected over a 32-month period in chronic SCI patients treated at the Veterans Affairs Medical Center SCI Unit. RESULTS: One hundred and twenty-three episodes of bacteremia occurred in 63 patients during 83 hospitalizations; 30 patients had multiple episodes of bacteremia. There were 1,644 admissions during this period, yielding an incidence of bacteremia of 7.5% (5.8% after excluding positive cultures that were believed to be caused by contaminants). The patients (31 with paraplegia and 32 with quadriplegia) had a mean age of 59 +/- 2 years, and a mean duration of injury of 23 +/- 2 years. Bladder management technique consisted of indwelling bladder catheter (n = 53), ileal conduit (n = 6), intermittent catheterization (n = 2), and spontaneous voiding (n = 2). Episodes of bacteremia were nosocomial in 89 out of 123 episodes. Multiple debilitating factors were present, including pressure ulcers in 36 out of 63 patients, chronic ventilator dependency in 5 out of 63 patients, recent surgical procedures in 17 out of 63 patients, underlying malignancy in 5 out of 63 patients, and evidence of malnutrition in 29 out of 63 patients (serum albumin concentration < 2.5 g/dL). Early mortality rate (death within 30 days of bacteremia) occurred in 8 out of 63 patients (13%) and late mortality (> 1 month following a bacteremic episode) occurred in 10 additional participants, such that total mortality was 1 8 out of 63 (29%). The sources of bacteremia were urinary tract infection (n = 39), presumed contaminant (n = 28), decubitus ulcers (n = 21), intravascular catheter (n = 19), pneumonia (n = 5), and other (n = 11). Gram-negative rods accounted for 26 out of 39 episodes of bacteremia from a urinary source. Methicillin-resistant Staphylococcus aureus, methicillin-sensitive S aureus, and coagulase-negative staphylococci were the predominant organisms when intravascular catheters or pressure ulcers were the source of bacteremia. CONCLUSION: In this population, bacteremia predominantly was caused by hospital-associated organisms, and occurred mainly in malnourished patients who required hospitalization for major underlying debilitating conditions, particularly pressure ulcers. Chronic indwelling bladder catheters and chronic vascular catheter usage also were highly prevalent in patients with bacteremic episodes. Hypoalbuminemia was the strongest independent predictor for mortality.

Palliative care and hematological malignancies: increased referrals at a comprehensive cancer centre.

BACKGROUND: Current evidence indicates that patients with hematological malignancies are less likely to receive input from specialist palliative care services compared to those with solid tumors. AIM: We aimed to analyze data for referrals to our palliative care service, in order to assess trends in the number and proportion of referrals received from hematology, and changes in the characteristics of these referrals. DESIGN: Prospective information was collected for all referrals to the Department of Pain and Palliative Care (DPPC) over a four-year period. This included inpatient/outpatient status, diagnosis, symptoms, and goals of the referring clinician; and information linked to hospital inpatient data to obtain date and location of death. SETTINGS/PARTICIPANTS: All hematology referrals were from January 2007 to December 2010. RESULTS: Hematology referrals constituted 11.6% of all referrals received during the study period. Outpatient referrals increased significantly with each year, as did the proportion of patients referred for symptom control. The median time from referral to death was 34 days, with poorest survival seen in acute leukemia and inpatients. Overall, 54% of inpatient hematology deaths had consultation from the DPPC, with these patients less likely to die in the intensive care unit. CONCLUSIONS: Over recent years, collaboration between hematology and palliative care has resulted in increased referral numbers, with potentially positive results for patients.

Successful daptomycin treatment for Staphylococcus lugdunensis endocarditis.

Staphylococcus lugdunensis, a coagulase-negative Staphylococcus species, is an increasingly relevant pathogen in the clinical setting. The organism has been isolated as a source of multiple clinical manifestations, including endocarditis. Herein, the authors present 2 cases of Staphylococcus lugdunensis endocarditis. These cases demonstrate the enhanced virulence and wide range of disease severity this organism creates. This enhanced virulence, undoubtedly present in these cases, led to novel daptomycin antibiotic regimen. To the best of the authors knowledge, these are the first reported cases using daptomycin in the treatment of Staphylococcus lugdunensis endocarditis.

Combination therapy efavirenz/emtricitabine/tenofovir disoproxil fumarate associated with hepatic failure.

A single pill daily fixed dose combination of Efavirenz, Emtricitabine, and Tenofovir Disoproxil Fumarate (EFV/FTC/TDF) provides a potent and convenient treatment option for HIV/AIDS. The components have been shown to be well tolerated and are effective in randomized controlled trials. A literature search revealed no case of hepatic failure reported with this drug combination. We here in describe the 1st case of acute hepatic failure developing after 3 months of treatment with EFV/FTC/TDF in a 41 year old African American male without pre-existing liver disease or risk factors.