Geriatric Communication Skills Training Program for Oncology Healthcare Providers: a Secondary Analysis of Patient and Caregiver Outcomes.

Geriatric cancer patients and their caregivers have unique needs that make it difficult for their healthcare providers (HCPs) to effectively communicate with them. As ineffective communication can lead to negative health outcomes, it is important that oncology HCPs receive specialized training on communication with older adult patients and their caregivers. We conducted a small pilot study examining audio recordings of clinical encounters between HCPs and older adult cancer patients/caregivers and questionnaires completed by the patients and their caregivers before and after the HCPs participated in a geriatric communication skills training program. Eleven HCPs completed the 6-h Geriatric Comskil Training. Two clinic consultations with unique geriatric patients (n = 44) and their caregivers (n = 29) were recorded before and after training and coded for HCPs' use of communication skills. Patients and caregivers also completed surveys measuring their satisfaction with HCP communication and perceived empathy. Analysis of the audio recordings revealed that HCPs did not increase their use of communication skills after training. Although our sample was too small to detect statistical significance, measures of effect size showed trending improvements in patients' and caregivers' perceptions of HCPs' empathy and satisfaction with their communication after training. Our findings build on previous studies evaluating the feasibility and effectiveness of the Geriatric Comskil Training in real world setting and indicate that the training may have improved HCPs' communication with older adult patients and their caregivers even if their use of their observable communication skills did not change.

On taking up space: a qualitative inquiry of depression in older adults with cancer.

OBJECTIVE: To identify the phenomenology of depression in older adults with cancer (OACs) in order to improve the accuracy of depression screening for this population. METHOD: Inclusion criteria were: ≥70 years old, history of cancer, no cognitive impairment or severe psychopathology. Participants completed a demographic questionnaire, a diagnostic interview, and a qualitative interview. Using a Thematic Content Analysis framework, critical themes, passages, and phrases used by patients to describe their perceptions of depression and how it is experienced were identified. Particular attention was paid to divergences between depressed and non-depressed participants. RESULTS: Among 26 OACs (13 depressed, 13 non-depressed), qualitative analyses revealed four major themes indicative of depression (i.e. anhedonia, reduction in social relationships/loneliness, lack of meaning and purpose, lack of usefulness/feeling like a burden) and four minor themes (i.e. attitude towards treatment, mood, regret/guilt, physical symptoms/limitations). Themes of adaptation and acceptance of symptoms also emerged. CONCLUSIONS: Of the eight themes identified, only two overlap with DSM criteria. This supports the need to develop assessment methods of depression in OACs that are less reliant on DSM criteria and distinct from existing measures. This may improve the ability to identify depression in this population.

Potential use of albumin and neutrophil-to-lymphocyte ratio to guide the evaluation and treatment of cancer-related depression and anxiety.

BACKGROUND: Depression and anxiety are common and associated with inflammation in patients with cancer. Inflammatory indices such as albumin and neutrophil-to-lymphocyte ratio (NLR) obtained from metabolic panels and complete blood counts should be available for mental health professionals treating anxiety and depression at cancer centers. We hypothesized that albumin and NLR extrapolated from non-mental health oncology appointments would be associated with anxiety and depression and drawn close enough to psychiatry visits to be useful for the psycho-oncologist. MATERIALS & METHODS: Depression and anxiety were evaluated in patients (n = 97) referred to a cancer center psychiatric service for depression using the Patient Health Questionnaire-9 and General Anxiety Disorder-7. Albumin concentration and NLR were assessed for timing and correlation strength with anxiety and depression by setting (localized/metastatic cancer). RESULTS: Most patients (96%) had albumin or NLR available at any time point of which 45% were drawn within one week of the psychiatric appointment. No significant correlations were noted when evaluating localized cancer or NLR exclusively. For patients with metastatic cancer, anxiety and depression were correlated with albumin at any time point (r = -0.28, p < 0.05; r = -0.40, p < 0.01, respectively) and within a week of psychiatry appointment (r = -0.40, p < 0.05; r = -0.68, p < 0.001, respectively). Albumin evaluated within a week predicted 32% of depression score variance (ß = -0.63, p = 0.002). Hypoalbuminemia (<3.8 g/ul) was associated with anxiety (χ2 = 4.43, p = 0.04) and depression (χ2 = 11.06, p = 0.001). CONCLUSION: Hypoalbuminemia in patients with metastatic cancer may help establish the presence or persistence of anxiety, depression, treatment refractoriness, and the use of inflammation in cancer-related psychological symptom management.

What Proportion of Patients With Musculoskeletal Sarcomas Demostrate Symptoms of Depression or Anxiety?

BACKGROUND: It is estimated that the 12-month prevalence of depression in the United States is 8.6%, and for anxiety it is 2.9%. Although prior studies have evaluated depression and anxiety in patients with carcinoma, few have specifically evaluated patients with sarcoma, who often have unique treatment considerations such as mobility changes after surgery. QUESTIONS/PURPOSES: We evaluated patients with sarcoma seen in our orthopaedic oncology clinic to determine (1) the proportion of patients with depression symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the nine-item Patient Health Questionnaire (PHQ-9), and if their symptoms varied by disease state; (2) the proportion of patients with anxiety symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the seven-item Generalized Anxiety Disorder Scale (GAD-7), and if they symptoms varied by disease state; (3) whether other factors were associated with the proportion and severity of symptoms of anxiety or depression, such as tumor location in the body (axial skeleton, upper extremity, or lower extremity), general type of tumor (bone or soft tissue), specific diagnosis, use of chemotherapy, length of follow-up (less than 1 year or greater than 1 year), and gender; and (4) what proportion of patients accepted referrals to mental health professionals, when offered. METHODS: This study was a cross-sectional survey study performed at a single urban National Cancer Institute-designated Comprehensive Cancer Center from April 2021 until July 2021. All patients seen in the orthopaedic clinic 18 years of age and older with a diagnosis/presumed diagnosis of sarcoma were provided the PHQ-9 as well as the GAD-7 in our clinic. We did not track those who elected not to complete the surveys. Surveys were scored per survey protocol (each question was scored from 0 to 3 and summed). Specifically, PHQ-9 scores the symptoms of depression as 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). The GAD-7 scores symptoms of anxiety as 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe). Patients with PHQ-9 or GAD-7 scores of 10 to 14 were referred to social work and those with scores 15 or higher were referred to psychiatry. Patients with thoughts of self-harm were referred regardless of score. Patients were divided based on disease state: patients during their initial management; patients with active, locally recurrent disease; patients with active metastatic disease; patients with prior recurrence or metastatic lesions who were subsequently treated and now have no evidence of disease (considered to be patients with discontinuous no evidence of disease); patients with no evidence of disease; and patients with an active, noncancerous complication but otherwise no evidence of disease. We additionally looked at the association of gender, chemotherapy administration, and tumor location on survey responses. Data are summarized using descriptive statistics. Differences across categories of disease state were tested for statistical significance using Kruskal-Wallis tests for continuous variables and Fisher exact tests for categorical variables as well as pairwise Wilcoxon rank sum tests. RESULTS: Overall, symptoms of depression were seen in 35% (67 of 190) of patients, at varying levels of severity: 19% (37 of 190) had mild symptoms, 9% (17 of 190) had moderate symptoms, 6% (12 of 190) had moderately severe symptoms, and 1% (1 of 190) had severe symptoms. Depresssion symptoms severe enough to trigger a referral were seen in 17% (32 of 190) of patients overall. Patients scored higher on the PHQ-9 during their initial treatment or when they had recurrent or metastatic disease, and they were more likely to trigger a referral during those timepoints as well. The mean PHQ-9 was 5.7 ± 5.8 during initial treatment, 6.1 ± 4.9 with metastatic disease, and 7.4 ± 5.2 with recurrent disease as compared with 3.2 ± 4.2 if there was no evidence of disease (p = 0.001). Anxiety symptoms were seen in 33% (61 of 185) of patients: 17% (32 of 185) had mild symptoms, 8% (14 of 185) had moderate symptoms, and 8% (15 of 185) had severe symptoms. Anxiety symptoms severe enough to trigger a referral were seen in 16% (29 of 185) of patients overall. Patients scored higher on the GAD-7 during initial treatment and when they had recurrent disease or an active noncancerous complication. The mean GAD-7 was 6.3 ± 3.2 in patients with active noncancerous complications, 6.8 ± 5.8 in patients during initial treatment, and 8.4 ± 8.3 in patients with recurrent disease as compared with 3.1 ± 4.2 in patients with no evidence of disease (p = 0.002). Patients were more likely to trigger a referral during initial treatment (32% [9 of 28]) and with recurrent disease (43% [6 of 14]) compared with those with no evidence of disease (9% [9 of 97]) and those with discontinuous no evidence of disease (6% [1 of 16]; p = 0.004). There was an increase in both PHQ-9 and GAD-7 scores among patients who had chemotherapy. Other factors that were associated with higher PHQ-9 scores were location of tumor (upper extremity versus lower extremity or axial skeleton) and gender. Another factor that was associated with higher GAD-7 scores included general category of diagnosis (bone versus soft tissue sarcoma). Specific diagnosis and length of follow-up had no association with symptoms of depression or anxiety. Overall, 22% (41 of 190) of patients were offered referrals to mental health professionals; 73% (30 of 41) accepted the referral. CONCLUSION: When treating patients with sarcoma, consideration should be given to potential concomitant psychiatric symptoms. Screening, especially at the highest-risk timepoints such as at the initial diagnosis and the time of recurrence, should be considered. Further work should be done to determine the effect of early psychiatric referral on patient-related outcomes and healthcare costs. LEVEL OF EVIDENCE: Level III, therapeutic study.

Decisional capacity determination and serious mental illness in oncology: Implications for equitable and beneficent care.

BACKGROUND: Patients with Serious Mental Illness (SMI) have worse survival compared to cancer patients without SMI after controlling for delayed diagnosis. Decision-making capacity (DMC) may be impaired in both populations (cancer or SMI). DMC may be further impaired based on coupled vulnerability factors that challenge Shared Decision Making (SDM) for patients with cancer and SMI. METHODS: Psychiatric consultations for DMC in hospitalized patients with cancer (n = 97) were consecutively evaluated across a single institution cancer center. SMI data, demographic, and cancer-related variables were obtained from the medical record. Descriptive data were contrasted in patients with and without DMC and used for logistic regression modeling. RESULTS: Overall, 42% had DMC with no significant differences based on SMI (χ2  = 2.60, p = 0.11). Patients with SMI were younger, receiving anticancer treatment, and were less likely facing end of life issues. Age (OR 1.03, p = 0.05) and no recent anticancer treatments (OR 0.34, p = 0.02) were associated with decisional incapacity. At 3 months post discharge, almost two-thirds were dead with no difference based on SMI (χ2  = 0.01, p = 0.91). But End of Life (EOL) concerns were documented in 63% of non-SMI patients and only 36% of SMI patients (χ2  = 5.63, p = 0.02). Healthcare proxy (16%), four determinates of DMC (22%), and repeated psychiatric DCM assessments (35%) were documented with no differences based on SMI. CONCLUSION: SDM is not equitable for cancer patients with SMI. Advanced directives and a robust effort to provide value-congruent care for patient with SMI who develop cancer may lessen this health inequity for cancer patients with SMI.

Decisional Capacity Determination In Patients With Cancer.

Patients with cancer face many difficult decisions and encounter many clinical situations that undermine decisional capacity. For this reason, assessing decision-making capacity should be thought of at every medical encounter. The culmination of variable disease trajectories, following patients to the end of life, use of high-risk treatments, and other weighty personal decisions require attention to patients' ability to engage in decisions. Oncologists develop meaningful relationships with their patients. This familiarity may lead to forgoing the process of diligently assessing a patient's cognitive ability and/or decisional capacity when important decisions need to be made. While the process may feel like it takes place spontaneously, many subtle and overt details are involved with the decisions around cancer care that require pointed questioning and probing. Thus, there are many ways to fall short in determining decisional capacity. Clinicians are inconsistent in their decisional capacity determinations and generally assume more decisional capacity than the patient has. Consult and referral services such as ethics and psychiatry can help with treatment decisions and with assessing underlying psychosocial and psychiatric conditions. Decisional capacity may fluctuate and requires a variable amount of decisional ability depending on the clinical situation; hence, it is time-specific and decision-specific. This review is intended to provide a summary of key components of decisional capacity while highlighting areas in need of clinical refinement.

Must antidepressants be avoided in patients with neuroendocrine tumors? Results of a systematic review.

OBJECTIVE: Symptoms of depression and anxiety are common in neuroendocrine tumor (NET), yet controversy exists over whether serotonin-mediated antidepressants (SAs) are safe in this population. We sought to address this knowledge gap. METHOD: Following PRISMA guidelines, we conducted a systematic review to identify NET patients who were prescribed SA. RESULTS: We identified 15 articles, reporting on 161 unique patients, 72 with carcinoid syndrome (CS) and 89 without. There was substantial agreement between reviewers at the full-text stage (κ = 0.69). Three of the articles, all with low risk of bias, accounted for most of the cases (149/161; 93%). Among the 72 NET patients with CS prior to antidepressant usage, CS was exacerbated in 6 cases (8%), only 3 (4%) of whom chose to discontinue the antidepressant. The remaining 89 patients had no prior CS symptoms, and none developed CS following antidepressant usage. Overall, no instances of carcinoid crisis or death were reported. CONCLUSIONS: We found no evidence for serious adverse outcomes related to SA usage in NET patients. Previous authors have recommended avoiding antidepressants in NET, but our findings do not support those recommendations. Oncologists should nonetheless monitor for symptom exacerbation when prescribing SA to patients with NET.

Addressing the quality of communication with older cancer patients with cognitive deficits: Development of a communication skills training module.

OBJECTIVE: Effective communication is an essential part of patient-centered care. The complexity of cancer care in older adults makes communication challenging, particularly when older patients have cognitive deficits and lose their autonomy. This paper describes the development, implementation, and evaluation of a communication skills training module for health care providers (HCPs) who work with older adults with cancer, with or at risk of developing cognitive deficits. METHOD: Using a pre-post single arm study design, 99 HCPs from a comprehensive cancer center in North-East USA, who worked primarily with geriatric patients, participated in the study. Participants included Advance Practice Providers (including Nurse Practitioners and Physician Assistants; n = 24, 24.2%); nurses (n = 23, 23.2%), social workers (n = 14, 14.1%), physicians (n = 13, 13.1%), and "other" HCPs (including occupational therapists, physical therapists, and psychologists; n = 20, 20.2%). The HCPs participated in a one-day geriatric communication skills training program in groups of 12-15 over a 2-year period. Participants complete pre-post surveys on module evaluation and perception of self-efficacy as well as pre-post video-recorded Standardized Patient Assessment (SPA) to evaluate communication skill uptake. RESULTS: Most participants evaluated the module positively; over 90% indicated that they agreed or strongly agreed with five of the six module evaluation items. HCPs' self-efficacy in communicating with cancer patients with cognitive deficits significantly increased from pre- to post-module training. There was a significant increase in the following communication skill use from pre- to post-training: checking patient preferences, declaring agenda, and inviting agenda. SIGNIFICANCE OF RESULTS: Results demonstrated a successful implementation of the program as evidenced through favorable program evaluation, significant gains in self-efficacy, as well as significant improvement in several communication skills.

Personality Disorders in Patients with Cancer.

Personality disorders exist on a spectrum in the general population and therefore may coexist in patients who have cancer. Patients with these disorders exhibit character rigidity resulting from enduring patterns of inner experience and behavior and may experience some level of interpersonal conflict among medical staff caring for them. These conditions become exacerbated under stressful cancer-related situations and may lead to adverse consequences and outcomes. This review highlights the conceptual and diagnostic issues of personality disorders for practicing oncologists and provides recommendations for recognizing and managing cancer patients with difficult personality traits or personality disorders.

Prevalence and predictors of depression, pain, and fatigue in older- versus younger-adult cancer survivors.

BACKGROUND: As the number of older adults in the United States continues to grow, there will be increasing demands on health care providers to address the needs of this population. Cancer is of particular importance, with over half of all cancer survivors older than 65 years. In addition, depression, pain, and fatigue are concerns for older adults with cancer and have been linked to poorer physical outcomes. METHODS: For this retrospective chart review, 1012 eligible participants were identified via a query of the Electronic Medical Record for all patients referred to 1 of 4 Survivorship Clinics at Memorial Sloan Kettering Cancer Center. All patients were between the ages of 30 to 55 (younger adults) and >65 (older adults). Depression was measured using the Patient Health Questionnaire-9 (PHQ-9). RESULTS: The overall rate of depression in this sample of adult cancer survivors was 9.3%. There were no differences in the rates of clinically significant depression (defined as PHQ-9 score ≥10) between younger and older adult cohorts. However, there was a small trend toward higher mean PHQ-9 scores in the younger adult cohort (3.42 vs 2.95; t = 1.763, P = .10). Women reported greater rates of depression and higher pain and fatigue scores. Hispanic/Latino patients also reported significantly greater rates of depression. CONCLUSION: There were no observed differences in depression between older and younger adult cancer survivors. Gender and ethnic discrepancies in depression were observed. Future research should focus on understanding the nature of these differences and targeting interventions for the groups most vulnerable to depression after cancer treatment.

High rate of thiamine deficiency among inpatients with cancer referred for psychiatric consultation: results of a single site prevalence study.

OBJECTIVE: Thiamine deficiency (TD) is increasingly recognized in medically ill patients. The prevalence of TD among cancer patients is unknown. This study aims to characterize the prevalence of TD among inpatients with cancer. METHODS: Retrospective chart review of patients admitted to a large cancer center who were referred for psychiatric consultation and whose serum thiamine concentration was measured. Patients with alcohol use were excluded. RESULTS: Among 217 patients with various cancer types, TD was found in 55.3%. Risk factors included fluorouracil-based chemotherapy, significant weight loss, and undergoing active cancer treatment. Almost all patients were normal weight, overweight, or obese, and few had concomitant vitamin B12 or folate deficiency. A total of 17.5% were receiving multivitamin supplementation. Nearly half (49.8%) did not receive empiric treatment with thiamine and among those who did, treatment delay occurred in the majority of cases (59.6%). Measurement of serum thiamine concentration preceded psychiatric consultation in only 10.6% of cases. CONCLUSIONS: Our findings suggest that TD is highly prevalent among inpatients with cancer, even among normal and overweight individuals, in the absence of other vitamin deficiencies, and while receiving multivitamin supplements. Several potential risk factors were identified, including active cancer treatment. Evaluation of TD was most commonly not initiated by oncologists. Failure to treat and treatment delay were common. Given these findings, oncologists must be vigilant about detecting TD among inpatients with cancer. Copyright © 2016 John Wiley & Sons, Ltd.

Diagnosing and Managing Delirium in Cancer Patients.

Delirium is frequently encountered when caring for cancer patients, from initial diagnosis to the advanced stages of the disease; however, it is often missed. Oncologists need to be familiar with the various defining features of the condition, and should be able to identify common underlying causes. We present a systematic approach to the workup, as well as pharmacologic and nonpharmacologic approaches to management. We discuss the common practice of treatment with neuroleptics, as well as recent controversy surrounding their use.

Nonalcoholic Thiamine-Related Encephalopathy (Wernicke-Korsakoff Syndrome) Among Inpatients With Cancer: A Series of 18 Cases.

BACKGROUND: Wernicke-Korsakoff Syndrome (WKS) is a neuropsychiatric syndrome caused by thiamine deficiency. Cancer predisposes to thiamine deficiency through various mechanisms. Although many case reports exist on nonalcoholic WKS in cancer, larger qualitative studies are lacking. METHOD: Retrospective study of patients admitted to a cancer hospital and diagnosed with WKS during routine care on a psychiatric consultation service. Only patients with at least 1 additional supporting feature (magnetic resonance imaging findings, low serum thiamine concentrations, or response to treatment) were included. Data pertaining to demographics, risk factors, phenomenology, and outcomes were abstracted from medical records by chart review. RESULTS: In all, 18 patients were included. All patients developed WKS during cancer treatment. Hematologic malignancy, gastrointestinal tract tumors, low oral intake, and weight loss were common risk factors. All patients presented with cognitive dysfunction, most commonly impaired alertness, attention, and short-term memory. All were diagnosed by operational criteria proposed by Caine et al., 1997 (where 2 of the following are required: nutritional deficiency, ocular signs, cerebellar signs, and either altered mental status or mild memory impairment). Few exhibited Wernicke's classic triad. Diagnostic and treatment delay were common. Only 3 patients recovered fully. CONCLUSION: Nonalcoholic WKS can occur during cancer treatment and manifests clinically as delirium. Diagnosis should be made using operational criteria, not Wernicke's triad. Most patients were not underweight and had normal serum concentration of vitamin B12 and folate. A variety of mechanisms might predispose to thiamine deficiency and WKS in cancer. Given the high frequency of residual morbidity, studies should focus on decreasing diagnostic and treatment delay.

Antipsychotic-induced akathisia in delirium: A systematic review.

OBJECTIVE: Akathisia is a neuropsychiatric syndrome characterized by subjective and objective restlessness. It is a common side effect in patients taking antipsychotics and other psychotropics. Patients with delirium are frequently treated with antipsychotic medications that are well known to induce akathisia as a side effect. However, the prevalence, phenomenology, and management of akathisia in patients with delirium remain largely unknown. The purpose of this review was to examine the medical literature in order to establish the current state of knowledge regarding the prevalence of antipsychotic-induced akathisia in patients with delirium. METHOD: A systematic review of the literature was conducted using the EMBASE, MEDLINE, PsycINFO, and CINAHL databases. Ten studies addressing the incidence of akathisia in patients taking antipsychotic medication for delirium were identified and included in our review. RESULTS: The included studies reported a variable prevalence of antipsychotic-induced akathisia. A higher prevalence was found in patients taking haloperidol. Among atypical antipsychotics, paliperidone and ziprasidone were associated with a higher risk of akathisia. The risk for akathisia appeared to be a dose-related phenomenon. SIGNIFICANCE OF RESULTS: Studies using specific scales for evaluation of akathisia in delirium are lacking. Some populations, such as patients with cancer or terminally ill patients in palliative care settings taking antipsychotics for the treatment of delirium, could be at higher risk for development of akathisia as a side effect.

A comprehensive review of palliative care in patients with cancer.

One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.

Assessment of Decision-Making Capacity in 97 Hospitalized Patients With Cancer: A Call for Standardization.

Hospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack decision making capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for consultation-liaison psychiatrists performing DMC assessments for patients with cancer. This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC. We conducted a retrospective chart review of 97 consecutive psychiatric consultations for DMC from 2017 to 2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, and emergency) and whether patients had decisional capacity. Out of 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation. Only 22% of DMC evaluation by consultation-liaison psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC. One-third of patients died in the hospital and two-thirds of patients were deceased 3 months after the consult. Given the substantial heterogeneity in the documentation of DMC evaluations in this retrospective chart review, we call for more rigor and standardization in documentation of DMC evaluations.

Addressing Challenges With Sedation in End-of-Life Care.

In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.

Drugs, delirium, and ethics at the end of life.

For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.

Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update.

PURPOSE: To update the ASCO guideline on the management of cancer-related fatigue (CRF) in adult survivors of cancer. METHODS: A multidisciplinary panel of medical oncology, geriatric oncology, internal medicine, psychology, psychiatry, exercise oncology, integrative medicine, behavioral oncology, nursing, and advocacy experts was convened. Guideline development involved a systematic literature review of randomized controlled trials (RCTs) published in 2013-2023. RESULTS: The evidence base consisted of 113 RCTs. Exercise, cognitive behavioral therapy (CBT), and mindfulness-based programs led to improvements in CRF both during and after the completion of cancer treatment. Tai chi, qigong, and American ginseng showed benefits during treatment, whereas yoga, acupressure, and moxibustion helped to manage CRF after completion of treatment. Use of other dietary supplements did not improve CRF during or after cancer treatment. In patients at the end of life, CBT and corticosteroids showed benefits. Certainty and quality of evidence were low to moderate for CRF management interventions. RECOMMENDATIONS: Clinicians should recommend exercise, CBT, mindfulness-based programs, and tai chi or qigong to reduce the severity of fatigue during cancer treatment. Psychoeducation and American ginseng may be recommended in adults undergoing cancer treatment. For survivors after completion of treatment, clinicians should recommend exercise, CBT, and mindfulness-based programs; in particular, CBT and mindfulness-based programs have shown efficacy for managing moderate to severe fatigue after treatment. Yoga, acupressure, and moxibustion may also be recommended. Patients at the end of life may be offered CBT and corticosteroids. Clinicians should not recommend L-carnitine, antidepressants, wakefulness agents, or routinely recommend psychostimulants to manage symptoms of CRF. There is insufficient evidence to make recommendations for or against other psychosocial, integrative, or pharmacological interventions for the management of fatigue.Additional information is available at www.asco.org/survivorship-guidelines.