A Randomized Controlled Trial of a CPR Decision Support Video for Patients Admitted to the General Medicine Service.

BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient's health is changing. Yet many patients are not adequately informed or involved in the decision-making process. OBJECTIVE: We examined the effect of an informational video about CPR on hospitalized patients' code status choices. DESIGN: This was a prospective, randomized trial conducted at the Minneapolis Veterans Affairs Health Care System in Minnesota. PARTICIPANTS: We enrolled 119 patients, hospitalized on the general medicine service, and at least 65 years old. The majority were men (97%) with a mean age of 75. INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60). MEASUREMENTS: The primary outcome was participants' code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants' trust in their healthcare team and knowledge and perceptions about CPR. RESULTS: Participants who viewed the video were less likely to choose full code (37%) compared to participants in the usual care group (71%) and more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (𝑃 < 0.00001). We did not see a difference in trust in their healthcare team or knowledge and perceptions about CPR as assessed by our questionnaire. CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.

Methadone-Induced Neurotoxicity in Advanced Cancer: A Case Report.

Methadone use as a second-line agent for severe cancer-related pain is increasing in the field of hospice and palliative care. It has a number of qualities that make its use favorable, including lack of known active metabolites and presumed relative safety from adverse effects such as opioid-induced neurotoxicity (OIN). This article describes a case of a patient undergoing treatment of severe cancer-related pain who developed OIN in the setting of oral methadone use. As the use of methadone increases, more research into its pharmacologic and pharmacokinetic properties will be necessary.

Where there is no morphine: the challenge and hope of palliative care delivery in Tanzania.

BACKGROUND: In Tanzania, a country of 42 million, access to oral morphine is rare. AIM: To demonstrate the effectiveness of palliative care teams in reducing patients' pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain. SETTING: One hundred and forty-fie cancer patients were included from 13 rural hospitals spread across Tanzania. METHOD: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than fie years' palliative care experience and no access to strong opioids. RESULTS: Patients and their family caregivers identifid statistically signifiant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefis from palliative care but also their great distress when 'bad cases' arose who would likely benefi only from oral morphine. CONCLUSION: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefis even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.

What the VA can teach us about geriatric care.

The innovation now being demanded by Medicare is creating new opportunities for health care organizations to redesign how they deliver care for elderly people. For many years, the VA Health System has experimented with ways to deliver care more effectively and efficiently. Hospital-based postacute and palliative care and home-based primary care are two examples of successful approaches that non-VA providers should be looking at as they move away from fee-for-service reimbursement and invent new care-delivery models.

Scaling up palliative care services in rural Tanzania.

Access to palliative care in Tanzania, particularly in rural areas, is limited. The Continuum of Care for People Living with HIV/AIDS in Tanzania (CHAT) project began in 2007 with the goal of expanding coverage of palliative care services. This was done by adding home-based palliative care teams to 13 existing hospitals throughout rural Tanzania. By integrating palliative care teams into the existing hospital structure and by using community resources, CHAT rapidly built a network of care. Community involvement and proper training of palliative care professionals and volunteers have allowed for an increasing number of patients to access and accept palliative care services and for CHAT to provide home-based palliative care, with clinical backup, to those in need.

Care for the most vulnerable children in Tanzania: a faith-based model of care and support for children affected by HIV.

In the fight against HIV and AIDS in sub-Saharan Africa, the plight of orphaned and vulnerable children was long overlooked. The first United Nations report on orphans and vulnerable children did not emerge until 2002 after more than two generations of children and youth had struggled to survive with limited family, institutional, or government support. The major social determinants of health for infants and children with one or more parents dying or dead from HIV include pervasive poverty, weak community social support systems, lack of policy commitment by governments or foreign donors, lack of access to anti-retroviral drugs, limited access to schools, and gender. In this paper, we present a model of care and support to the most vulnerable children (MVC) affected by HIV that brings together faith-based institutions in partnership with the government and community volunteers in 13 rural districts of Tanzania. Although still being implemented, the project has a number of valuable lessons learned for program managers, donors, and researchers working with faith-based organizations in the development and delivery of services to the most vulnerable children in a resource-limited setting.