How are agitated patients dealt with in internal medicine departments?

Background: Studies on agitation in internal medicine departments are scarce, especially regarding how doctors and nurses act in these situations. The objective of this study was to clarify how agitation is dealt with in these departments. Methods: This prospective observational study was performed in the internal medicine departments of four Portuguese hospitals. The researchers at each hospital contacted the nursing team that identifies patients who were agitated in the previous shifts. The researcher reviewed these patients' files, recording the research protocol's parameters. Results: During the study period, 331 patients were observed; 177 (54%) were female, and the median age was 80 years (19-99). Episodes of agitation occurred in 69 patients (21%); of them, 44 (64%) were female, and the median age was 84 years (31-98). In the first episode of agitation, the doctor on duty was called in 49 times (71%). These doctors prescribed a new medication for the crisis in 30 cases (43%). After the crisis, the assistant doctor recorded the episode in the patient file in 41 cases (59%). According to the medical notes, after the acute phase, in only 21 patients (30%), there was an attempt to clarify the cause of agitation. The prescription after the crisis was regular medication in 32 cases (46%), rescue medication in 27 (39%), and physical restraint in 9 (13%), isolated or in various combinations. Conclusion: This study suggests that there is room to improve how agitated patients are managed in internal medicine departments.

Continuous Sedation in Palliative Care in Portugal: A Prospective Multicentric Study.

Objective: This study aimed to survey the practice of palliative sedation in Portugal, where data on this subject were lacking. Methods: This was a prospective multicentric study that included all patients admitted to each team that agreed to participate. Patients were followed until death, discharge, or after 3 months of follow-up. Results: The study included 8 teams: 4 as palliative care units (PCU), 1 as a hospital palliative care team (HPCT), 2 as home care (HC), and 1 as HPCT and HC. Of the 361 patients enrolled, 52% were male, the median age was 76 years, and 285 (79%) had cancer. Continuous sedation was undergone by 49 (14%) patients: 26 (53%) were male, and the median age was 76. Most patients, 46 (94%), had an oncological diagnosis. Only in a minority of cases, the family, 16 (33%), or the patient, 5 (10%), participated in the decision to sedate. Delirium was the most frequent symptom leading to sedation. The medication most used was midazolam (65%). In the multivariable analysis, only age and the combined score were independently associated with sedation; patients <76 years and those with higher levels of suffering had a higher probability of being sedated. Conclusions: The practice of continuous palliative sedation in Portugal is within the range reported in other studies. One particularly relevant point was the low participation of patients and their families in the decision-making process. Each team must have a deep discussion on this aspect.

Aggressiveness in systemic anticancer therapy at the end of life in an oncology center.

Introduction: An increasing aggressiveness in cancer treatment at the end of life (EoL) has been reported in several, but not all, countries. This study aimed to see how aggressive cancer treatment is at the EoL in an oncology center. Methods: Retrospective study of patients 18 years or older with a solid cancer diagnosis who died in 2017. The focus was systemic anticancer therapy (SACT), excluding hormonotherapy. Results: In 2017, 2024 patients with solid tumors died. Of those patients, 1262 (62%) were male, and the median age was 69 (range 19-97) years. The most frequent primary cancer was lung cancer, followed by colorectal and stomach cancers, and 740 (37%) patients had metastatic disease. The median interval between SACT and death was 61 days. Of the patients undergoing SACT, 216 (27%) did it in the last month of life, 174 (22%) between 8 and 30 days from death, and 42 (5%) in the last week. On multivariable analysis, head and neck, colorectal, breast, and melanoma primaries; age group (older than 65 years); and metastatic disease had statistical significance associated with SACT. Of these variables, only metastatic disease is more likely to undergo SACT. Conclusion: This study confirms the relatively frequent aggressiveness in cancer treatment at the EoL. Taking into consideration previously published data, it can be tentatively concluded that the use of SACT increased in the last month and the last week of life.

Factors Associated With Long Survival in Patients With Cancer Admitted to Palliative Care: An Exploratory Study.

Objective: Some patients with cancer admitted to palliative care have relatively long survivals of 1 year or more. The objective of this study was to find out factors associated with prolonged survival. Methods: Retrospective case-control study comparing the available data of patients with cancer who survived more than 1 year after admission in a palliative care service with patients with cancer who survived 6 months or less. The intended proportion was 4 controls for each case. Patients were identified through electronic records from 2012 until 2018. Results: And 1721 patients were identified. Of those patients, 111 (6.4%) survived for at least 1 year, and 363 (21.1%) were included as controls according to the established criteria. The intended proportion could not be reached; the proportion was only 3.3:1. The median survival of cases was 581 days (range: 371-2763), and the median survival of controls was 57 days (range: 1-182). In the multivariable analysis, patients with a hemoglobin ≥ 10.6 g/dL and a creatinine level >95 µmol/L had a higher probability of living more than 1 year. In contrast, patients with abnormal cognition, pain, anorexia, liver metastases, an Eastern Cooperative Oncology Group performance status >1, and a neutrophil/lymphocyte ratio ≥ 3.43 had a low probability of living more than 1 year. Conclusion: Several factors were statistically associated positively or negatively with prolonged survival. However, the data of this study should be confirmed in other studies.

Percutaneous gastrostomies in advanced cancer.

Introduction: Gastrostomies can be performed percutaneously by interventional radiology (PRG) or endoscopy (PEG). Methods: Retrospective analysis of patients with advanced cancer who underwent a gastrostomy in 2017 in an oncology center. Results: In 2017, 164 patients underwent gastrostomies, and 137 (84%) were male. The median age was 60 years (range: 38-91). The predominant Eastern Cooperative Oncology Group (ECOG) performance status stage was 1, with 73 (45%) patients. Head and neck cancer was the most common diagnosis, with 127 (77%) cases. The most frequent reason for performing a gastrostomy was dysphagia, 132 (81%). Most gastrostomies were PEG, 121 (74%), followed by PRG, 41 (25%), and surgery, 2 (1%). Early complications occurred in 86 (52%) patients, and the most frequent of them were local pain in 69 (80%) patients and minor local bleeding in 13 (15%). Late complications occurred in 90 (55%) patients, and the most frequent was also local pain in 57 (63%) patients, followed by local infection in 8 (9%), tube extrusion in 7 (8%), and stomal leakage in 7 (8%). In the multivariable analysis, the factors associated with survival were lymph node metastases and the ECOG performance status. Until June 30th, 2022, 123 (75%) patients had died, and 41 (25%) were still alive. Conclusion: Gastrostomies were performed predominantly in ECOG performance stage 1 patients with head and neck cancer and symptoms of dysphagia, and PEG was the most common procedure.

Complications of Biliary Drainage in Patients with Malignant Biliary Obstruction.

PURPOSE: Biliary tract obstruction in cancer patients is usually associated with a poor prognosis. The obstruction may cause distressing symptoms, such as pruritus. As this situation occurs mostly in advanced cancer, the primary objective of the treatment is in many cases symptom control and not prolonging life. However, some patients can be candidates for chemotherapy. To see the outcomes of stenting insertion in patients of our oncology center. METHODS: A retrospective study of patients who have undergone this procedure between 1 October 2011 and 31 December 2018 was carried out. RESULTS: Insertion of a biliary stent was performed in 171 patients. The most common diagnoses were gastric and colorectal cancers, each with 42 (24%), followed by pancreatic (34 (20%)) and biliary tract cancer (25 (14%)). Most stents (155 (91%)) were placed percutaneously. Complications were seen in 91 (53%) patients and the most common was cholangitis in 48 (53%) patients, and the median survival was 75.5 days (3-1246). A total of 168 (98%) patients were referred to palliative care. In a multivariable analysis, the ECOG performance status was associated with survival, with the ECOG 0, 1, and 2 associated with better survival and peritoneal metastases associated with lower survival. CONCLUSIONS: For many patients with advanced cancers, it may not be clear if the benefits of palliative biliary stents outweigh the risks. Therefore, the problem should be discussed with the patients and their families, making clear the goals of care and the potential benefits and risks that can be expected.

Use of Alfentanil in Palliative Care.

Alfentanil is used for chronic pain relief in palliative care. However, there is a dearth of data on its use. For this reason, a decision was made to review the use of alfentanil in palliative care. Retrospective study was carried out in a palliative care service. The files of patients who received alfentanil as an intravenous or subcutaneous continuous infusion for pain relief, between January 2018 and April 2019. In total, 111 patients received alfentanil out of 113 admissions. Of them, 56 were male, and the median age was 70 years. The median number of days on alfentanil was 6 (range 1 to 129). The most frequent primary reasons for switching to alfentanil was uncontrolled pain in 52 (46%) patients and renal impairment in 24 (21%) patients. The median 24-h initial dose of alfentanil was 4 mg (1-20), and the median final 24-h dose of alfentanil was 5 mg (1-60), (p < 0.001). The initial 24-h median number of rescue doses was 2 (0-8), and the final median number of rescue doses was 1 (0 to 8), (p = 0.025). In 56 patients who were on alfentanil for at least 7 days, the dose decreased in 3 (5%), remained stable in 10 (18%) and increased in 43 (77%). The patient on alfentanil for 129 days maintained the same dose throughout that period. Alfentanil can be a useful second-line opioid. The induction of tolerance does not seem to be particularly rapid with alfentanil.

Bowel obstruction in advanced cancer.

PURPOSE: Assessment of treatment of cancer patients with bowel obstruction, identification of prognostic factors, and assessment of reference to palliative care. METHODS: Records of patients with a diagnosis of bowel obstruction over a 6-month (January-June 2013) period were reviewed. RESULTS: Seventy-five patients were diagnosed with bowel obstruction. Fifty-one (68%) were female and the median age was 65 years (27-100). The most frequent cancer was colorectal, 30 (40%), followed by gynecological cancer, 20 (27%). Forty-three (57%) patients underwent conservative treatment; 26 (35%) underwent surgery; and 6 (8%) had a stent placement. In 68 (91%), the bowel obstruction was resolved. Three years after the bowel obstruction episode, 15 (20%) patients were still alive. An analysis of the possible association of variables recorded with mortality was carried out, and for death at the first admission, only the resolution of the obstruction was significant (P < .001); for the 3-year survival the significant factors were hemoglobin >10.7 g/dL (P < .001) and ascites (P = .001) at the time of obstruction. Thirty-seven (49%) patients were referred to palliative care. CONCLUSIONS: Although bowel obstruction in cancer patients is usually associated with a short life expectancy, some patients have relatively long survivals. Only about half of the patients were referred to palliative care.

Hypocalcemia in cancer patients: An exploratory study.

INTRODUCTION: Calcium has several physiological functions and when it registers abnormal serum levels those functions may be impacted with potentially severe consequences. There is much research on hypercalcemia in cancer patients, but there are no recent studies on the prevalence of hypocalcemia in those patients. However, there has been an evolution in oncology, namely, new drugs that may directly or indirectly result in hypocalcemia. The primary aim was to explore the association of hypocalcemia with the diverse types of cancer. The secondary aim was to study the influence that hypocalcemia might have on survival. METHODS: Review of the records of patients ≥18 years old, with total calcium <2.0 mmol/L measured in 2013 in a cancer center. RESULTS: Eight hundred twenty-nine patients were included. Four hundred thirty-nine (53%) were male. The median age was 63 years. The most frequent cancer diagnoses were hematological 196 (24%) and colorectal 111 (13%). Six hundred thirty-eight patients had measured serum albumin, with a median of 25.5 g/L (14-47). When corrected for albumin level, calcium was in the normal range in 210 (33%) cases. The median survival of patients with corrected calcium lower than normal was 479 days (95% confidence interval [CI]: 309-649) and that of patients with normal corrected calcium was 62 days (95% CI: 33-91), P < .001. In a multivariate analysis, age, primary cancer, and albumin were significantly associated with survival. CONCLUSION: Hypocalcemia is associated with several types of cancer. A low calcium level is not by itself a factor of a poor prognosis since other factors seem to be more important.

Family physicians' opinions on and difficulties with breaking bad news.

HIGHLIGHTS: Breaking bad news is still deemed a difficult task by family physicians.Family physicians feel they need training in breaking bad news.The family physicians' attitude to this issue is different from what they would wish if they themselves had a life-threatening disease. BACKGROUND: Family practice is the specialty with the highest number of doctors and covers all of Portugal. Therefore, the attitude of these doctors may have a high impact on patients. OBJECTIVE: To explore the opinion and difficulties of Portuguese family doctors on dealing with communication with patients with life threatening diseases. METHODS: A questionnaire was sent to about 10% of family doctors of Northern Portugal. The questionnaire included questions about the disclosure of information, if they feel they need training courses and what they would want if they had a life-threatening disease. RESULTS: A questionnaire was given to 196 doctors and 159 (81%) participated in this study. The median age was 43 years (26-64) and 108 (68%) were females. One hundred thirty-five (85%) consider that breaking bad news is a difficult task. One hundred twenty-four (78%) feel they need training in breaking bad news. For many doctors, the disclosure of diagnoses and prognoses has a detrimental psychological effect and affects patients' hope, but gives patients' control of the situation. Given a situation where the doctors themselves had a life-threatening disease, the vast majority would want to know the diagnosis and the prognosis and to participate in treatment decisions. CONCLUSIONS: Breaking bad news is still a difficult task. Their attitude to this duty is different from what they would wish if they themselves had a life-threatening disease. One important conclusion is the need of specific training in communication for family physicians that should begin in the training phase of their specialty.

Comparison of Haloperidol Alone and in Combination with Midazolam for the Treatment of Acute Agitation in an Inpatient Palliative Care Service.

Agitation is a very distressing problem that must be controlled as quickly as possible, but using a safe method. The authors conducted a comparison of two protocols: a combination of haloperidol and midazolam and haloperidol alone. The combination drug protocol controlled 101 out of 121 (84%) episodes of agitation with only the first dose, whereas the haloperidol alone protocol controlled 47 out of 74 (64%) episodes. This difference is statistically significant (P =.002), with a post hoc analyzed power of 0.88. The median time from the first dose to the control of agitation was 15 minutes (range: 5-210) with the combination and 60 minutes (range: 10-430) with the other protocol, P <.001. There were no complications other than some transient somnolence, mainly with the combination protocol. The authors conclude that the combination of haloperidol and midazolam is effective and safe for the control of agitation in palliative care and it is more effective than haloperidol alone. Therefore, the combination should be adopted as the preferred protocol. It would be helpful if the usefulness of this protocol is confirmed by others.

Initial assessment of patients without cognitive failure admitted to palliative care: a validation study.

OBJECTIVE: Many assessment tools have been developed for palliative care and there are a number of differences between them. Therefore, we felt that there was room for improvement. METHODS: In a previous study, the relevant items were selected by a Delphi process with international experts in palliative care. A 5-point verbal scale was added to the items selected and adapted to the different kind of items. RESULTS: The study included 123 patients, 63 (51%) were female and the median age was 64 (37 to 88). A four-factor structure was found through the principal components analysis, explaining 60.1% of the total variance. The scale presented good reliability, with a Cronbach's alpha of 0.72. It was hypothesized as a validity of construct that as the total symptom burden increased, survival time would decrease. This hypothesis was confirmed by the statistical analysis performed. A hazard ratio of 1.016 (P=0.019) was obtained in the Cox regression model including the final score as an explanatory variable of survival time, which means that for each increment of 1% in the total score, there was an increased risk of death of 1.6%. CONCLUSIONS: This tool is in accordance with the recommended characteristics that an assessment tool should have. It is simple to administer and easy to explain, complete and analyze. It is also a valid tool.

Assessment of discomfort in patients with cognitive failure in palliative care.

OBJECTIVE: When cognitive impairment precludes patients' report of symptoms, it becomes necessary to use other means. The purpose of our study was to evaluate the validity of the method currently in use on our service. METHOD: Two members of the team simultaneously assessed the patient and independently recorded whether the patient showed signs of discomfort, and a third questioned patients with cognitive failure who maintained some ability to respond if something was bothering them. RESULTS: Some 200 assessments were made of 116 patients. The kappa coefficient of agreement was 0.615. The sensitivity was 17% and specificity 99%. The positive predictive value was 88%, and the negative predictive value was 73%. SIGNIFICANCE OF RESULTS: Due to the low sensitivity of this method, it cannot be recommended as a screening tool.