European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit.

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

Home hospice for older people with advanced dementia: a pilot project.

BACKGROUND: Dementia is a terminal illness making the palliative and hospice approach to care appropriate for older people with advanced dementia. OBJECTIVE: To examine clinical and health services outcomes of a quality improvement pilot project to provide home hospice care for older people with advanced dementia. STUDY DESIGN: Twenty older people with advanced dementia being treated in the Maccabi Healthcare Services homecare program, received home hospice care as an extension of their usual care for 6-7 months (or until they died) from a multidisciplinary team who were available 24/7. Family members were interviewed using validated questionnaires about symptom management, satisfaction with care, and caregiver burden. Hospitalizations prevented and medications discontinued, were determined by medical record review and team consensus. FINDINGS: The findings are based on 112 months of care with an average of 5.6 (SD 1.6) months per participant. The participants were on average 83.5 (SD 8.6) years old, 70% women, in homecare for 2.8 (SD 2.0) years, had dementia for 5.6 (SD 3.6) years with multiple comorbidities, and had been hospitalized for an average of 14.0 (SD 18.1) days in the year prior to the project. Four patients were fed via artificial nutrition. During the pilot project, 4 patients died, 2 patients withdrew, 1 patient was transferred to a nursing home and 13 returned to their usual homecare program. The home hospice program lead to significant (p < 0.001)improvement in: symptom management (score of 33.8 on admission on the Volicer symptom management scale increased to 38.3 on discharge), in satisfaction with care (27.5 to 35.3,), and a significant decline in caregiver burden (12.1 to 1.4 on the Zarit Burden index). There were five hospitalizations, and 33 hospitalizations prevented, and an average of 2.1(SD 1.4) medications discontinued per participant. Family members reported that the professionalism and 24/7 availability of the staff provided the added value of the program. CONCLUSIONS: This pilot quality improvement project suggests that home hospice care for older people with advanced dementia can improve symptom management and caregiver satisfaction, while decreasing caregiver burden, preventing hospitalizations and discontinuing unnecessary medications. Identifying older people with advanced dementia with a 6 month prognosis remains a major challenge.

Correction to: home hospice for older people with advanced dementia: a pilot project.

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Depression in primary care in Israel.

Depression is a leading cause of morbidity, disability and health care utilization. It is commonly encountered in primary care settings yet is often missed or suboptimally managed. We summarize studies conducted in Israel on the prevalence of depression in primary care settings, its correlates, and predictors of treatment and outcome, and discuss their implications for clinical practice and public health policy. An electronic search was conducted using the MEDLINE and PsychINFO databases. The inclusion criteria were original studies that assessed aspects of depression in a population aged 18 or older, were conducted in primary care settings in Israel, and had sufficient detailed description of depression-related measures, study sample and outcome measures. Twelve articles reporting results from seven studies met these criteria. The prevalence of current depression in primary care varied considerably across studies: 1.6-5.9% for major depression, 1.1-5.4% for minor depression, 14.3-24% for depressive symptoms. Depression was consistently related to female gender and fewer years of education, and was associated with disability, decreased quality of life, and increased health-related expenditure. Many cases of depression were undiagnosed and most patients had persistent depression or achieved only partial remission. Depression represents a serious challenge for the primary health care system in Israel. Greater efforts should be focused on screening and treating depression in primary care. However, the studies reviewed here used different methodologies and assessed different aspects of depression and, therefore, should be generalized cautiously. Systematic research on the prevalence, correlates and management of depression in primary care, with emphasis on collaborative care models, is strongly needed to inform research, clinicians and health care policy makers.

Evaluating palliative care needs in Middle Eastern countries.

BACKGROUND: Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. OBJECTIVE: To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. DESIGN: Descriptive survey. SETTING/SUBJECTS: Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. MEASUREMENTS: Palliative care needs assessment. RESULTS: Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. CONCLUSIONS: The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.

Relieving the burden: palliative centesis of an oedematous scrotal wall due to anasarca in end-stage heart failure.

End-stage congestive heart failure is a leading diagnosis among hospice patients without cancer. As in terminally ill cancer patients; the aim of the treatment was to focus on palliation and maximum symptom relief. Anasarca, a widespread swelling of the skin because of effusion of fluid into the extracellular space, is a common sign in end-stage heart failure causing much pain and discomfort. We described a simple, safe, bed-side technique to alleviate the discomfort associated with massive scrotal oedema.