Too little, too late: Palliation and end-stage liver disease.

BACKGROUND AND AIM: End-stage liver disease is a leading cause of mortality. Fewer than 60% of patients with decompensated cirrhosis survive after 2 years, with patients often experiencing distressing symptoms impairing quality of life. Early advanced care planning and timely palliative care referral can improve quality of life and the end of life experience. We aimed to determine palliative care referral rates and patterns for patients admitted with decompensated cirrhosis, and to identify the factors associated with referral. METHODS: This was a retrospective, single-center study undertaken at a metropolitan tertiary referral hospital. Patients admitted between the 1 June 2016 and 31 January 2019 with a Child-Pugh score of B or C, and a model for end-stage liver disease score ≥ 15 were included. We assessed survival and compared those referred and not referred to palliative care, adjusting for lag-time to referral (Kaplan-Meier analysis). RESULTS: One-hundred and sixteen admissions met eligibility criteria for referral. The median age at admission was 59 years, with 76% male participants. Only a fifth of eligible patients (25/116) were referred to palliative care. The median survival (from referral) for those referred to palliative care was 20 days, versus 148 days for those not referred. CONCLUSIONS: Despite benefits from timely referral, less than one quarter of palliative care eligible patients was referred. Referral appears reserved for those facing imminent death-surviving just under 3 weeks postreferral, yet mortality in nonreferred patients remained high (148-day median). Low rates and late referral are a missed opportunity to improve the end of life care for patients with end-stage liver disease.

Accuracy of medication information sources compared to the best possible medication history for patients presenting to the emergency department.

OBJECTIVE: To assess the accuracy of medication information sources available for adult patients presenting to the ED, compared to a best possible medication history (BPMH). METHODS: This prospective observational study was undertaken in the ED of a major tertiary-referral teaching hospital. A convenience sample of consecutive adult patients taking one or more regular medications was included. A BPMH was ascertained using patient/carer interviews, where available, and confirmed with one or more other sources. For residential care facility (RCF) patients, the RCF medication chart and at least one other source were used. Information sources compared with the BPMH were community pharmacy dispensing history, patient's own medications, patient's medication list, general practitioner letter, medications stored in and labelled on dose administration aids (DAAs) and the RCF chart. Number of discrepancies per patient for each source was determined by comparing medications and dose regimens to those documented in the BPMH. RESULTS: A total of 455 patients (median age 71 years) took a median of six 'regular' and two 'as required' medications. The median number (range) of discrepancies per patient for regular medication names and dosages were RCF chart 0 (0-3), DAA contents 2.0 (0-9), patient's medication list 2.5 (0-16), DAA medications label 3.0 (0-7), community pharmacy history 3.0 (0-19), general practitioner letter 3.0 (0-18) and patient's own medications 4.0 (0-16). Overall, 40.4% of discrepancies were deemed 'moderate' or 'high' clinical significance. Omission errors accounted for 55.6% of discrepancies. CONCLUSIONS: A combination of sources is essential to determine the BPMH. RCF charts provided the most accurate information. Other sources had two to four regular medication-related discrepancies per patient.

The Period Prevalence of Mind and Body Practice Use by Adult Emergency Department Patients.

OBJECTIVES: Mind and Body Practice (MBP) use (e.g., chiropractic, acupuncture, meditation) among Emergency Department (ED) patients is largely unknown. We aimed to determine the period prevalence, nature of MBP use, and perceptions of MBP among adult ED patients. DESIGN AND SETTING: We undertook a cross-sectional survey of a convenience sample of patients presenting to three EDs between February and June 2016. SUBJECTS: Patients were eligible for inclusion if they were aged 18 years or more and had presented for medical treatment. INTERVENTION: An anonymous, self-administered questionnaire, based upon a validated pediatric questionnaire, was completed by the patient, with assistance if required. OUTCOME MEASURES: The primary outcome was the nature and 12 month period prevalence of MBP use. Secondary outcomes were variables associated with use and patient perceptions of MBP. RESULTS: 674 patients were enrolled. In the previous 12 months, 500 (74.2%) patients had used at least one MBP. MBP users and nonusers did not differ in gender, ancestry, or chronic illness status (p > 0.05). However, users were significantly younger and more likely to have private health insurance (p < 0.001). A total of 2094 courses of 68 different MBP had been used including massage (75.0% of users), meditation (35.2%), chiropractic (32.6%), acupuncture (32.0%), and yoga (30.6%). Users were significantly more likely (p < 0.01) to believe that MBP prevented illness, treated illness, were more effective than prescription medicines, assisted prescription medications, and were safe and provided a more holistic approach. Forty-one (6.1%) patients used MBP for their ED presenting complaint. However, only 14 (34.1%) advised their ED physician of this. CONCLUSION: The period prevalence of MBP use among ED patients is high. Knowledge of the MBP used for a patient's presenting complaint may better inform the ED physician when making management decisions.

Community asthma management of emergency department patients: A pilot study of adherence with national consensus guidelines.

We aimed to determine whether the outpatient management of ED patients with asthma adheres to Australia's Asthma Consensus Guidelines. Adult patients, under treatment for asthma, were administered a validated questionnaire. Data on their outpatient management were collected and analysed descriptively. Of 51 patients, 14 smoked and 35 did not undergo regular GP review. Twenty-one patients had a good understanding of a written asthma action plan although only 15 owned one. Fourteen patients used no preventer medication. Patients were only able to identify a mean of 3.4 asthma triggers. Most patients' management does not adhere to Australian guidelines.

Adherence to national exercise guidelines by patients attending emergency departments: A multi-site survey.

OBJECTIVE: The proportion of adults in Australia meeting or exceeding the national guidelines for physical activity has remained relatively static over the past 10 years. The research objective was to measure self-reported physical activity and sedentary behaviour among ED patients in accordance with Australia's current physical activity and sedentary behaviour guidelines, revised in 2014. METHODS: A convenience sample of participants was recruited from three EDs in Melbourne between February and May 2016. Eligible participants were administered the International Physical Activity Questionnaire - Short Form plus researcher-derived questions. Participants were assessed as whether meeting the physical activity guidelines or not, using pre-defined criteria. RESULTS: The proportion of 18-64 year olds meeting all of the physical activity guidelines was 19.0% (95% confidence interval [CI] 15.2-22.8). A majority of participants (63.1%, 95% CI 58.5-67.7) met the aerobic component of the guidelines although only 28.9% (95% CI 24.5-33.3) of participants reported undertaking strength building exercises two or more times per week. Adults in the oldest age group were found to be less likely to engage in muscle strengthening exercises (23.3%, n = 30) than those in the youngest age group (40.0%, n = 60, P = 0.005). Average daily sitting time (minutes) did not differ between men (median = 300) and women (median = 360, P = 0.118). CONCLUSIONS: Overall adherence with physical activity guidelines is low among adults attending the ED. All adults need to be encouraged to undertake muscle strengthening activities, especially adults in older age groups.