Anxiety, depression, and end-of-life care utilization in adults with metastatic cancer.

OBJECTIVE: End-of-life care for patients with cancer is often overly burdensome, and palliative and hospice care are underutilized. The objective of this study was to evaluate whether the mental health diagnoses of anxiety and depression were associated with variation in end-of-life care in metastatic cancer. METHODS: This study used electronic health data from 1,333 adults with metastatic cancer who received care at two academic health centers in Louisiana, USA, and died between 1/1/2011-12/31/2017. The study used descriptive statistics to characterize the sample and logistic regression to examine whether anxiety and depression diagnoses in the six months before death were associated with utilization outcomes (chemotherapy, intensive care unit [ICU] visits, emergency department visits, mechanical ventilation, inpatient hospitalization, palliative care encounters, and hospice utilization), while controlling for key demographic and health covariates. RESULTS: Patients (56.1% male; 65.6% White, 31.1% Black) commonly experienced depression (23.9%) and anxiety (27.2%) disorders within six months of death. Anxiety was associated with an increased likelihood of chemotherapy (odds ratio [OR] = 1.42, p = 0.016), ICU visits (OR = 1.40, p = 0.013), and inpatient hospitalizations (OR = 1.85, p < 0.001) in the 30 days before death. Anxiety (OR = 1.95, p < 0.001) and depression (OR = 1.34, p = 0.038) were associated with a greater likelihood of a palliative encounter. CONCLUSIONS: Patients with metastatic cancer who had an anxiety disorder were more likely to have burdensome end-of-life care, including chemotherapy, ICU visits, and inpatient hospitalizations in the 30 days before death. Depression and anxiety both increased the odds of palliative encounters. These results emphasize the importance of mental health considerations in end-of-life care.

Racial Disparities in End-of-Life Care Between Black and White Adults With Metastatic Cancer.

CONTEXT: The comfort of patients with cancer near the end of life (EOL) is often undermined by unnecessary and burdensome treatments. There is a need for more research examining racial disparities in EOL care, especially in regions with a history of racial discrimination. OBJECTIVES: To examine whether black adults received more burdensome EOL care than white adults in a population-based data set of cancer decedents in Louisiana, a state with a history of slavery and long-standing racial disparities. METHODS: This was a retrospective analysis of EOL care from the Research Action for Health Network (REACHnet), a regional Patient-Centered Outcomes Research Institute-funded database. The sample consisted of 875 white and 415 black patients with metastatic cancer who died in Louisiana from 2011 to 2017. We used logistic regression to examine whether race was associated with five indicators of burdensome care in the last 30 days of life: chemotherapy use, inpatient hospitalization, intensive care unit admission, emergency department (ED) admission, and mechanical ventilation. RESULTS: Most patients (85.0%) received at least one indicator of burdensome care: hospitalization (76.5%), intensive care unit admission (44.1%), chemotherapy (29.1%), mechanical ventilation (23.0%), and ED admission (18.3%). Odds ratios (ORs) indicated that black individuals were more likely than white individuals to be hospitalized (OR = 1.66; 95% CI = 1.21-2.28; P = 0.002) or admitted to the ED (OR = 1.57; 95% CI = 1.16-2.13; P = 0.004) during their last month of life. CONCLUSION: Findings have implications for informing health care decision making near the EOL for patients, families, and clinicians, especially in regions with a history of racial discrimination and disparities.

Primary palliative care for the general internist: integrating goals of care discussions into the outpatient setting.

BACKGROUND: Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. CASE REPORT: Here we present the case of a 71-year-old male patient with chronic obstructive pulmonary disorder, congestive heart failure, and newly diagnosed Alzheimer dementia to model pertinent end-of-life care communication and discuss practical tips on how to incorporate it into practice. CONCLUSION: General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients.

Teaching palliative care in the intensive care unit: how to break the news.

BACKGROUND: Palliative care education is often lacking in graduate medical education curricula. Studies show that many physicians are uncomfortable discussing end-of-life issues with patients and providing palliative care to dying patients and their families. We used a case-based approach to improve resident confidence in delivering bad news, discussing poor prognoses, explaining the dying process, and providing palliative care in the intensive care unit. METHODS: The medical intensive care unit (MICU) curriculum involved a 3-pronged approach, including role modeling by the attending physician and palliative care team, tutorials, and a case-based debriefing at the end of each month-long rotation. Case-based debriefing consisted of discussions by the house officers of cases they encountered during the MICU rotation. Sessions were moderated by a staff physician trained in palliative care and a palliative care advanced practice nurse. Open-ended questions stimulated the residents' reflection on their decisions and guided the discussion pertinent to palliative care. Using a survey instrument with a 4-point Likert scale, house officers assessed themselves before and after the rotation, rating their confidence in 9 areas of palliative care. Paired t tests were used to compare the cohort's scores before and after the rotation. RESULTS: A total of 214 house officers completed prerotation and postrotation surveys from April 2007 to September 2011. After completing the course, house officers demonstrated statistically significant improvement in confidence with conducting family conferences (mean 2.6 before vs 3.1 after [P<0.001]), delivering bad news (mean 3.1 before vs 3.5 after [P<0.001]), discussing do not resuscitate orders (3.1 before vs 3.6 after [P<0.001]), discussing comfort care (mean 2.8 before vs 3.4 after [P<0.001]), discussing withdrawal of life-sustaining treatment (mean 2.6 before vs 3.2 after [P<0.001]), managing pain (mean 3.0 before vs 3.5 after [P<0.001]), managing terminal symptoms (mean 2.8 before vs 3.4 after [P<0.001]), assessing decision-making capacity (mean 2.8 before vs 3.4 after [P<0.001]), and discussing advance directives (mean 2.8 before vs 3.4 after [P<0.001]). CONCLUSION: Using a multidisciplinary team to teach a structured curriculum that includes a case-based debriefing improves house officer confidence in discussing end-of-life care and providing palliative care to patients in the intensive care setting.

The role of palliative care at the end of life.

The goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients. As death approaches, a patient's symptoms may require more aggressive palliation. As comfort measures intensify, so should the support provided to the dying patient's family. After the patient's death, palliative care focuses primarily on bereavement and support of the family.

A rare case of Candida arthritis in a hemodialysis patient.

Patients on maintenance hemodialysis are particularly prone to opportunistic infections because of their increased exposure to antibiotics, frequent vascular access, and altered cellular immunity. This case report discusses a 63-year-old African American patient on maintenance hemodialysis who presented with acute painful swelling of her left knee and fever. She was diagnosed to have septic arthritis, candidemia, and arteriovenous (AV) graft infection caused by Candida albicans. The management included removal of the infected AV graft, intravenous fluconazole, and arthrotomy with lavage. The Candida infection subsided, but the patient continued to have knee swelling because of chronic synovitis. We believe that this is the first case of acute Candida septic arthritis in a patient with end-stage renal disease, where hematogenous spread was proven by positive C. albicans cultures from the blood, AV graft, and synovial fluid.

Education does pay off: pneumococcal vaccine screening and administration in hospitalized adult patients with pneumonia.

Streptococcus pneumoniae-associated infections are an important cause of hospitalization and mortality in high-risk and elderly patients. Even in the setting of appropriate therapy, the case fatality rate of invasive pneumococcal disease in the elderly may approach 40%. Since approximately 40,000 people die annually from pneumococcal-associated disease, it represents a substantial target for vaccine-preventable, bacterial fatalities. The 23-valent pneumococcal polysaccharide vaccine has proven consistently effective in preventing invasive pneumococcal disease. Despite its endorsement by numerous specialty societies, the pneumococcal vaccine is underutilized in the inpatient setting. In a recent report of quality indicators for Medicare beneficiaries, the percentage of Medicare beneficiaries in Louisiana admitted with pneumonia who were screened or received the pneumococcal vaccination prior to discharge was only 4%, the lowest percentage in the United States. The Louisiana State University-New Orleans Internal Medicine Department and its house staff embarked upon a retrospective study to determine its baseline pneumococcal vaccination or screening rates for all patients with pneumonia on its inpatient services at the The Medical Center of Louisiana in New Orleans from July 2000 through June 2001. From July 2001 through June 2002 an intensive educational intervention concentrating on the indications and benefits of pneumococcal vaccination was directed toward the Louisiana State University Internal Medicine house staff assigned to the inpatient service. Retrospective analysis for pneumococcal vaccine screening and administration of charts of all patients with pneumonia on the LSU Medicine service from July 2001 through June 2002 was performed in order to determine the effects of the intervention. Data from the pre-educational intervention period revealed a baseline pneumococcal vaccine screening or administration rate of 11% for all patients with pneumonia on the LSU Internal Medicine inpatient service. During the one-year intervention period, the pneumococcal vaccine screening or administration rate increased to 71%, a clinically and statistically significant increase (p-value < 0.0001). Data targeting patients 65 years of age and older revealed a baseline pneumococcal vaccine screening or administration rate of 10% for patients with pneumonia on the LSU Internal Medicine inpatient service which increased to 82% during the one year educational intervention (p-value < 0.0001). House officer scores (possible range 0-100) on a questionnaire assessing their understanding of the indications and benefits of pneumococcal vaccination were significantly higher after the educational intervention compared to before the intervention (means +/- standard deviations, 68 +/- 9 vs. 59 +/- 10, p < 0.0001). The findings from this study highlight the importance of education in increasing compliance with widely-accepted practice guidelines such as pneumococcal vaccine screening or administration in patients hospitalized with pneumonia.