Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life.

INTRODUCTION: Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE: This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS: We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS: Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS: Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data.

PURPOSE: Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. METHODS: Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. RESULTS: A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. CONCLUSION: This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

Primary palliative care in the ICU.

ABSTRACT: Despite the best efforts of modern health care and critical care providers, many patients in the intensive care unit (ICU) will still die each year. The need for palliative care services in the ICU is common. Although specialty palliative care services provide excellent care and are a tremendous resource, every critical care provider should be able to provide the basics of palliative care themselves through the model of primary palliative care. Although it may be uncomfortable for the critical care provider at first, providing palliative care to our ICU patients can be a very rewarding experience. In this article, I discuss best practices for handling difficult conversations with patients and their families, helping patients and families make difficult decisions regarding the goals of care, and managing symptoms at the end of life.

Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life.

BACKGROUND: The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents' hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents' hospital transfers at the end-of-life. METHODS: 1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. RESULTS: Senior staff request GPs to prescribe ICDs ahead of residents' expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. CONCLUSION: Senior staff use GPs' prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner's referral.

[Palliative care in paediatric oncology - a national parental perspective]. / Palliativ vård av barn med cancer.

The WHO definition of paediatric palliative care (PPC) emphasises the role of active multidimensional care, carried out with interdisciplinary competence, and providing support to the entire family. The aim of the current national study was to investigate whether parents perceived that their child received palliative care (PC) before the child died of cancer and the parent's view of the care during the child's last month of life. In 2016, parents (n=226) completed a study-specific survey, and a majority reported that their child had received PC with good professional competence. However, many parents reported that the child was greatly affected by pain in the last month of life. Geographical differences indicated that parents who live in sparsely populated areas to a lesser extent reported that their child received PC. Lastly, our conclusion is that access to equal PPC and improved symptom control is crucial for children and their families.

Aldosterone levels do not predict 28-day mortality in patients treated for COVID-19 in the intensive care unit.

The immunotropic effects of aldosterone might play a role in COVID-19, as SARS-CoV-2 reportedly uses angiotensin-converting enzyme 2 receptors as an entry point into cells. Aldosterone function is closely linked to its action on mineralocorticoid receptors in kidneys; it increases the renal retention of sodium and the excretion of potassium, which increases blood pressure. Despite the large number of studies examining the effect of Ang-II and its blockers on the course of COVID-19 infection, there is still uncertainty about the role of aldosterone. The aim of the study was to assess the correlation of aldosterone, urea, creatinine, C-reactive protein (CRP), and procalcitonin (PCT) levels with 28 days of mortality in patients treated for COVID19 in an intensive care unit (ICU). This cross-selection study involved 115 adult patients who were divided into two groups: those who died within a 28-day period (n = 82) and those who survived (n = 33). The correlation of aldosterone, urea, creatinine, C-reactive protein (CRP), and procalcitonin (PCT) levels with 28 days of mortality in patients treated for COVID-19 were performed. The patients' age, sex, scores from the APACHE II, SAPS II, and SOFA scales and comorbidities like HA, IHD and DM were also analyzed. Remarkably, the individuals who survived for 28 days were of significantly lower mean age and achieved notably lower scores on the APACHE II, SAPS II, and SOFA assessment scales. Statistically significantly higher CRP levels were observed on days 3, 5, and 7 in individuals who survived for 28 days. Creatinine levels in the same group were also statistically significantly lower on days 1, 3, and 5 than those of individuals who died within 28 days. The investigation employed both univariate and multivariate Cox proportional hazard regression models to explore factors related to mortality. In the univariate analysis, variables with a p value of less than 0.50 were included in the multivariate model. Age, APACHE II, SAPS II, and SOFA demonstrated significance in univariate analysis and were considered to be associated with mortality. The outcomes of the multivariate analysis indicated that age (HR = 1.03, p = 0.033) served as a robust predictor of mortality in the entire study population. In conclusion the plasma aldosterone level is not associated with ICU mortality in patients with COVID-19. Other factors, including the patient's age, creatinine or CRP contribute to the severity and prognosis of the disease. This study was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) with registration no. ACTRN12621001300864 (27/09/2021: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382563&isReview=true ).

[THE MULTIDISCIPLINARY GERIATRIC SURGERY UNIT AT THE CHAIM SHEBA MEDICAL CENTER - FIRST YEAR OF ACTIVITY].

INTRODUCTION: Recently, a Geriatric Surgery Unit (GSU) was established in the Sheba Medical Center. The Unit's aims include: professional assessment of surgical candidates, approval of the surgical plan by a multidisciplinary team discussion (MTD), and meeting the specific needs of the geriatric patient undergoing surgery. METHODS: We describe the establishment of the GSU and preliminary results from the first year of its activity (January-December 2022). The GSU team consisted of a geriatric nurse practitioner (NP), a geriatric physician, surgeons, anesthesiologists and a physiotherapist. Inclusion criteria for GSU assessment/treatment were age>80 years or substantial baseline geriatric morbidity. RESULTS: In 2022, 276 patients were treated by the GSU: 110 underwent elective comprehensive preoperative assessment in the NP clinic and the rest were assessed urgently/semi-electively during their hospitalization. One hundred and fifteen cases (median age 86 (65-98) years) were brought to MTD and considered for elective cholecystectomy (46.1%), colorectal procedures (16.5%), hernia repair (13.9%), hepatobiliary procedures (9.6%) or other surgeries (13.9%); of those, 49 patients (median age 86 (72-98) years) eventually proceeded to surgery, following which the median length of hospital stay (LOS) was 3.5 (1-60) days and the rate of postoperative complications was 46.7%. After discharge, the median duration of follow-up was 2.5 (0-18) months during which 4 patients died. Compared with geriatric patients who underwent cholecystectomy during 2021-2023 without MTD (n=39), in the cases discussed by the MTD, patients (n=17) had a shorter LOS (2.0±0.9 vs. 2.4±2.1 days), less 30-day Emergency Department referrals (12.5% vs. 28.2%) and less 30-day re-admissions (6.2% vs. 15.4%; all p≥0.3). CONCLUSIONS: Geriatric surgical patients require a designated professional approach to meet their unique perioperative needs. The effect of GSUs on perioperative outcomes merits further prospective studies.

[SUCCESSFUL AGING-A MULTI-FUNCTIONAL DIMENSION CONCEPT AN EMPHASIS ON THE END OF LIFE].

INTRODUCTION: The concept of "successful aging" as coined by Rowe and Kahan in the late nineties of the last century, came to describe a period of old age with multi-functional abilities. The functions are physical, cognitive and social, without progressive chronic diseases and without disabilities. There is a change in the concept of successful aging beyond the physical dimension (daily function (ADL) and cognitive function) which is based on objective performance indicators towards subjective indicators based on the patients' feelings and their quality of life. Successful aging moves from the limited bio-physical aspect to an overall view of bio-psycho-socio which means mental-emotional-behavioral aspects, social involvement, and also an element of spirituality and even end-of-life decisions. Successful aging will be measured by objective and subjective measures that include the patient's feelings and experiences. The idea is to include and see in successful aging not only the absence of morbidity and disability as seen by Rowe and Kahan, but to a multidimensional function that includes physical and cognitive, mental and emotional, social and spiritual parameters and a dimension of the end of life in making decisions according to the wishes and preferences of the person himself and his family.

Pérdida significativa como factor del alcoholismo / Perda significativa como fator de alcoolism / Significant loss as a factor in alcoholism

La relación de la pérdida significativa de un ser queridoy el alcoholismo ha minimizado las implicaciones sobremecanismos de afrontamientos para generar conductassaludables. Este artículo se basa en entrevistas semiestructuradasa profundidad en hombres de entre 30 y 70 años, conmás de 10 años en Alcohólicos Anónimos del Estado deTamaulipas, México. El objetivo fue reflexionar sobre lossignificados de la pérdida significativa de un ser querido yel alcoholismo. En la búsqueda del significado, se explicaque un factor que lleva al alcoholismo no es una sola pérdidasignificativa de personas queridas, sino un cúmulo tambiende pérdidas materiales y no materiales, se reflejaron recursoslimitados para afrontar las pérdidas, la relación entre lapérdida significativa con el alcoholismo fue mediado pordos principales aspectos, las creencias sobre los efectos queproduce el consumo de alcohol como formas de escapar de larealidad y las influencia de la familia al inicio del consumode alcohol. Por otra parte, la presencia de lo espiritual, laconciencia y las emociones que experimentan durante suproceso de duelo y alcoholismo, los llevó a identificar elproblema de la adicción, que permitió influir en el procesode rehabilitación.(AU)

A relação entre a perda significativa de um ente querido e oalcoolismo tem minimizado as implicações nos mecanismosde enfrentamento para gerar comportamentos saudáveis.Este artigo é baseado em entrevistas semiestruturadas emprofundidade com homens entre 30 e 70 anos, com mais de10 anos em Alcoólicos Anônimos no Estado de Tamaulipas,México. O objetivo foi refletir sobre os significados da perdasignificativa de um ente querido e do alcoolismo. Na buscade sentido, explica-se que um fator que leva ao alcoolismonão é uma única perda significativa de entes queridos, mastambém um acúmulo de perdas materiais e imateriais,recursos limitados foram refletidos para enfrentar as perdas,a relação entre a perda significativa com o alcoolismo foimediada por dois aspectos principais, as crenças sobre osefeitos que o consumo de álcool produz como formas defuga da realidade e a influência da família no início doconsumo de álcool. Por outro lado, a presença do espiritual,da consciência e das emoções que vivenciam durante oprocesso de luto e alcoolismo, levaram-nos a identificar oproblema da dependência, o que lhes permitiu influenciaro processo de reabilitação.(AU)

The relationship between the significant loss of a lovedone and alcoholism has minimized the implications oncoping mechanisms to generate healthy behaviors. Thisarticle is based on in-depth semi-structured interviews withmen between the ages of 30 and 70, with more than 10years in Alcoholics Anonymous in the State of Tamaulipas,Mexico. The objective was to reflect on the meanings of the significant loss of a loved one and alcoholism. In thesearch for meaning, it is explained that a factor that leadsto alcoholism is not a single significant loss of loved ones,but also an accumulation of material and non-materiallosses, limited resources were reflected to face the losses,the relationship between the loss significant with alcoholismwas mediated by two main aspects, beliefs about the effectsthat alcohol consumption produces as ways of escapingfrom reality and the influence of the family at the beginningof alcohol consumption. On the other hand, the presenceof the spiritual, the conscience and the emotions that theyexperience during their mourning process and alcoholism,led them to identify the problem of addiction, which allowedthem to influence the rehabilitation process.(AU)

Financial impact of donation after circulatory death heart transplantation: A single-center analysis.

INTRODUCTION: Clinical success of donation after circulatory death (DCD) heart transplantation is leading to growing adoption of this technique. In comparison to procurement from a brain-dead donor, DCD requires additional resources. The economic impact of DCD heart transplantation from the hospital perspective is not well known. METHODS: We compared the financial data of patients who received DCD allografts to those who received a DBD organ at our institution from January 1, 2021 to December 31, 2022. We also compared the cost of ex-situ machine perfusion to in-situ organ perfusion employed during DCD recovery. RESULTS: We performed 58 DBD and 22 DCD heart-alone transplantations during the study period. Out of 22 DCD grafts, 16 were recovered with thoracoabdominal normothermic regional perfusion (TA-NRP) and six with direct procurement followed by normothermic machine perfusion (DP-NMP). The contribution margin per case for DBD versus DCD was $234,362 and $235,440 (P = .72). The direct costs did not significantly differ between the two groups ($171,949 and 186,250; P = .49). In comparing the two methods of procuring hearts from DCD donors, the direct cost of TA-NRP was $155,955 in comparison to $223,399 for DP-NMP (P = .21). This difference translated into a clinically meaningful but not statistically significant greater contribution margin for TA-NRP ($242, 657 vs. $175,768; P = .34). CONCLUSIONS: Our data showed that the adoption of DCD procurement did not have a negative financial impact on the contribution margin in our institution. Programs considering starting DCD heart transplantation, and those who are currently performing DCD procurement should evaluate their own financial situation.

Stepwise development and expansion of an abdominal normothermic regional perfusion program for donation after circulatory determination of death organ procurement.

INTRODUCTION: Normothermic regional perfusion (NRP) represents an innovative technology that improves the outcomes for liver and kidney recipients of donation after circulatory determination of death (DCD) organs but protocols for abdominal-only NRP (A-NRP) DCD are lacking in the US. METHODS: We describe the implementation and expansion strategies of a transplant-center-based A-NRP DCD program that has grown in volume, geographical reach, and donor acceptance parameters, presented as four eras. RESULTS: In the implementation era, two donors were attempted, and one liver graft was transplanted. In the local expansion era, 33% of attempted donors resulted in transplantation and 42% of liver grafts from donors who died within the functional warm ischemic time (fWIT) limit were transplanted. In the Regional Expansion era, 25% of attempted donors resulted in transplantation and 50% of liver grafts from donors who died within the fWIT limit were transplanted. In the Donor Acceptance Expansion era, 46% of attempted donors resulted in transplantation and 72% of liver grafts from donors who died within the fWIT limit were transplanted. Eight discarded grafts demonstrated a potential opportunity for utilization. CONCLUSION: The stepwise approach to building an A-NRP program described here can serve as a model for other transplant centers.

Question prompt list intervention for patients with advanced cancer: a systematic review and meta-analysis.

BACKGROUND: Enhanced communication in end-of-life care (EOL) improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life. Question prompt list (QPL) has been shown to enhance physician-patient communication in patients with cancer, but there is a lack of systematic review and meta-analysis for those with advanced cancer. Enhanced communication in end-of-life care improves preparation and treatment decisions for patients with advanced cancer, affecting their quality of life at the end of life. OBJECTIVE: To review the effectiveness of QPL intervention on physician-patient communication and health outcomes during consultation in patients with advanced cancer. METHODS: CINAHL, Embase, Scopus, and PsycINFO databases were undertaken using inclusion criteria for relevant articles up to August 2021. Pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated using random-effects models. We used the Cochrane risk-of-bias assessment tool and modified Jadad scale to assess the quality of the studies. RESULTS: Seven RCTs with 1059 participants were included, of which six studies were eligible for the meta-analysis. The pooled meta-analysis results indicated that QPL in patients with advanced cancer had a significant positive effect on the total number of questions asked (SMD, 0.73; 95% CI, 0.28 to 1.18; I2 = 83%) and on the patients' expectations for the future (SMD, 0.67; 95% CI, 0.08 to 1.25; I2 = 88%). There were no significant improvements in health-related outcomes such as end of life, anxiety, and quality of life. CONCLUSIONS: Using QPL in advanced cancer consultations boosts patient questions which helps communication but not health-related indicators. Optimal results depend on full reading, but timing varies. Future research should examine the relationship between communication and health outcomes, including patient/physician behavior and social context.

Development and Validation of a Machine Learning-Based Model of Mortality Risk in First-Episode Psychosis.

Importance: There is an absence of mortality risk assessment tools in first-episode psychosis (FEP) that could enable personalized interventions. Objective: To examine the feasibility of machine learning (ML) in discerning mortality risk in FEP and to assess whether such risk predictions can inform pharmacotherapy choices. Design, Setting, and Participants: In this prognostic study, Swedish nationwide cohort data (from July 1, 2006, to December 31, 2021) were harnessed for model development and validation. Finnish cohort data (from January 1, 1998, to December 31, 2017) were used for external validation. Data analyses were completed between December 2022 and December 2023. Main Outcomes and Measures: Fifty-one nationwide register variables, encompassing demographics and clinical and work-related histories, were subjected to ML to predict future mortality risk. The ML model's performance was evaluated by calculating the area under the receiver operating characteristic curve (AUROC). The comparative effectiveness of pharmacotherapies in patients was assessed and was stratified by the ML model to those with predicted high mortality risk (vs low risk), using the between-individual hazard ratio (HR). The 5 most important variables were then identified and a model was retrained using these variables in the discovery sample. Results: This study included 24 052 Swedish participants (20 000 in the discovery sample and 4052 in the validation sample) and 1490 Finnish participants (in the validation sample). Swedish participants had a mean (SD) age of 29.1 (8.1) years, 62.1% were men, and 418 died with 2 years. Finnish participants had a mean (SD) age of 29.7 (8.0) years, 61.7% were men, and 31 died within 2 years. The discovery sample achieved an AUROC of 0.71 (95% CI, 0.68-0.74) for 2-year mortality prediction. Using the 5 most important variables (ie, the top 10% [substance use comorbidities, first hospitalization duration due to FEP, male sex, prior somatic hospitalizations, and age]), the final model resulted in an AUROC of 0.70 (95% CI, 0.63-0.76) in the Swedish sample and 0.67 (95% CI, 0.56-0.78) in the Finnish sample. Individuals with predicted high mortality risk had an elevated 15-year risk in the Swedish sample (HR, 3.77 [95% CI, 2.92-4.88]) and an elevated 20-year risk in the Finnish sample (HR, 3.72 [95% CI, 2.67-5.18]). For those with predicted high mortality risk, long-acting injectable antipsychotics (HR, 0.45 [95% CI, 0.23-0.88]) and mood stabilizers (HR, 0.64 [95% CI, 0.46-0.90]) were associated with decreased mortality risk. Conversely, for those predicted to survive, only oral aripiprazole (HR, 0.38 [95% CI, 0.20-0.69]) and risperidone (HR, 0.38 [95% CI, 0.18-0.82]) were associated with decreased mortality risk. Conclusions and Relevance: In this prognostic study, an ML-based model was developed and validated to predict mortality risk in FEP. These findings may help to develop personalized interventions to mitigate mortality risk in FEP.

Noninvasive monitoring technologies to identify discomfort and distressing symptoms in persons with limited communication at the end of life: a scoping review.

BACKGROUND: Discomfort and distressing symptoms are common at the end of life, while people in this stage are often no longer able to express themselves. Technologies may aid clinicians in detecting and treating these symptoms to improve end-of-life care. This review provides an overview of noninvasive monitoring technologies that may be applied to persons with limited communication at the end of life to identify discomfort. METHODS: A systematic search was performed in nine databases, and experts were consulted. Manuscripts were included if they were written in English, Dutch, German, French, Japanese or Chinese, if the monitoring technology measured discomfort or distressing symptoms, was noninvasive, could be continuously administered for 4 hours and was potentially applicable for bed-ridden people. The screening was performed by two researchers independently. Information about the technology, its clinimetrics (validity, reliability, sensitivity, specificity, responsiveness), acceptability, and feasibility were extracted. RESULTS: Of the 3,414 identified manuscripts, 229 met the eligibility criteria. A variety of monitoring technologies were identified, including actigraphy, brain activity monitoring, electrocardiography, electrodermal activity monitoring, surface electromyography, incontinence sensors, multimodal systems, and noncontact monitoring systems. The main indicators of discomfort monitored by these technologies were sleep, level of consciousness, risk of pressure ulcers, urinary incontinence, agitation, and pain. For the end-of-life phase, brain activity monitors could be helpful and acceptable to monitor the level of consciousness during palliative sedation. However, no manuscripts have reported on the clinimetrics, feasibility, and acceptability of the other technologies for the end-of-life phase. CONCLUSIONS: Noninvasive monitoring technologies are available to measure common symptoms at the end of life. Future research should evaluate the quality of evidence provided by existing studies and investigate the feasibility, acceptability, and usefulness of these technologies in the end-of-life setting. Guidelines for studies on healthcare technologies should be better implemented and further developed.