The use of pentobarbital in cases of severe delirium: a case series.

Delirium is a common syndrome present at the end of life and causes significant distress for patients and families. Sleep disruption is a common precipitating factor for delirium and restoration of sleep may be instrumental in attenuating symptoms. In this cases series, we present three patients who were unresponsive to escalating doses of standard delirium medications, but whose delirium resolved once improved sleep was achieved using Pentobarbital. In a fourth patient, delirium was successfully treated where neuroleptics were contraindicated. Pentobarbital has been shown to reduce the time to sleep onset, decrease the number of body movements during sleep and spontaneous awakenings and increase the total sleep time. Pentobarbital may provide an additional treatment option for patients whose delirium is refractory to standard management approaches.

The nature and timing of family-provider communication in late-stage cancer: a qualitative study of caregivers' experiences.

CONTEXT: Family members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved one's illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future. OBJECTIVES: Guided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers' accounts of the nature and timing of communication they had with a loved one's health care provider(s) during the advanced stages of cancer and before hospice enrollment. METHODS: Retrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes. RESULTS: Overall, communication with providers was found to be either 1) satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death. CONCLUSION: Communication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.

Effects of methylphenidate on fatigue and depression: a randomized, double-blind, placebo-controlled trial.

CONTEXT: Fatigue is highly prevalent in populations with advanced illness and is often associated with depressed mood. The role of psychostimulant therapy in the treatment of these conditions remains ill defined. OBJECTIVES: To evaluate the response of fatigue and depression in patients with advanced illness to titrated doses of methylphenidate (MP) as compared with placebo. METHODS: In a randomized, double-blind, placebo-controlled trial, 30 hospice patients, both inpatients and outpatients, who had fatigue scores of at least four on a scale of zero to 10 (0=no fatigue and 10=worst fatigue), were randomly assigned to receive either 5mg of MP at 8 am and 1 pm or placebo. Doses of MP were titrated every three days according to response and adverse effects. Home care patients were monitored daily by telephone and visited by a research nurse on Study Days 0 (baseline), 3, 7, and 14. Fatigue was assessed using the Piper Fatigue Scale as the primary outcome measure and validated by the Visual Analogue Scale for Fatigue and the Edmonton Symptom Assessment Scale (ESAS) fatigue score. Subjects in inpatient facilities were interviewed or assessed by staff on an identical schedule. Depressive symptoms were assessed by the Beck Depression Inventory-II, Center for Epidemiologic Studies Depression Scale, and the ESAS depression score. Primary statistical analysis was conducted using repeated-measures multivariate analysis of the variance. RESULTS: Both MP- and placebo-treated groups had similar measures of fatigue at baseline. Patients taking MP were found to have significantly lower fatigue scores (Piper Fatigue Scale, Visual Analogue Scale for Fatigue, and ESAS) at Day 14 compared with baseline. The improvement in fatigue with MP treatment was dose-dependent; the mean average effective dose was 10mg on Day 3 and 20mg on Day 14 (dose range of 10-40 mg). Placebo-treated individuals showed no significant improvement in fatigue. For patients with clinically significant depression on Day 0, treatment with MP was associated with a significant reduction in all test indices for depressed mood. For the placebo group, the changes in measures of depression were less than observed in the treatment group but were inconsistent between assessment tools. No significant toxicities were observed. CONCLUSION: MP reduced symptoms of fatigue and depression when compared with placebo. The effect of MP on fatigue was dose-dependent and sustained over the duration of the study.

The use of ketamine in severe cases of refractory pain syndromes in the palliative care setting: a case series.

The benefits of ketamine in reducing pain are largely based on case reports and small clinical trials. We present a case series describing the application and efficacy of subanesthetic doses of ketamine in the treatment of complex pain syndromes poorly responsive to escalating doses of opioids. The discussion that follows suggests that subanesthetic intravenous ketamine can be used to successfully treat severe pain of different etiologies refractory to opioid dose escalation. Optimal dosing titration, duration of initial treatment, and the role of maintenance ketamine need to be further elucidated. Our case series adds to the extant literature supporting the role of subanesthetic ketamine for refractory pain problems.

Length of survival in hospice for cancer patients referred from a comprehensive cancer center.

This retrospective study examined 180 hospice patients referred from a comprehensive cancer center over 6 months in 2002 to (1) identify the variables associated with shorter length of survival (LOS) in hospice and (2) examine the LOS in hospice for those who previously participated in clinical trials and/or phase I studies. The median LOS in hospice for this cohort was 35 days. In multivariate analysis, low Palliative Performance Score (PPS) at hospice enrollment and male gender were associated with shorter LOS in hospice: males with low PPS had the shortest LOS while females with high PPS had the longest LOS. No correlation was found between the LOS in hospice and prior participation in clinical trials and/or phase I studies.

Length of survival of patients with cancer in hospice: a retrospective analysis of patients treated at a major cancer center versus other practice settings.

This is a retrospective study of the length of survival (LOS) in hospice of patients with cancer treated at a major cancer center compared to other treatment sites. Of 670 patients, the 185 (28%) treated at a major cancer center had unique characteristics, including higher median Palliative Performance Score (PPS) at the time of hospice enrollment (45 versus 40, p = 0.009), and longer median LOS in hospice (35 versus 21 days, p = 0.02: log rank test). Additional variables that predicted longer LOS were higher PPS, Medicare or Medicaid, self-referral, unmarried status, and non-executed advance directives. After adjusting survival for PPS with a Cox proportional hazard model, the hazard ratio for PPS remained statistically significant (95% confidence interval [CI]: 0.95-0.97] while that for the treatment site was not (95% CI: 0.73-1.04]. The performance status, and not the treatment site, was the dominant predictor of the LOS of patients with cancer in hospice.

Outcomes from a national multispecialty palliative care curriculum development project.

BACKGROUND: In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery. OBJECTIVE: To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project. MEASUREMENT: Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports. RESULTS: Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. CONCLUSIONS: Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.

Understanding family responses to life-limiting illness: In-depth interviews with hospice patients and their family members.

Understanding family dynamics is a key component in providing comprehensive care for persons with progressive illnesses and their caregivers. The purpose of this study was to investigate what families experience during an advancing illness and to describe their pattems of response. In-depth interviews (n=108) were conducted with families two weeks after hospice admission. Interviews were tape recorded, transcribed, and analyzed using qualitative methods. Six modes were distilled: reactive (illness generates intense responses), advocacy (vulnerability ignites assertive actions), fused (illness and decline are shared experiences), dissonant (diametrically opposed viewpoints cause struggle), resigned (decline and death are anticipated), and closed (outward responses are impassive). Three events triggered movement from one mode to another: (1) functional changes, (2) crisis events, and (3) provider communication. Providers who understand varied family reactions can ease the patient's suffering, assist relatives in providing effective care, and prepare them for the approaching death.

Final transitions: family caregiving at the end of life.

BACKGROUND: This study aimed to understand how caregivers make the transition to end-stage caregiving and to illuminate its unique aspects using a stress process model. METHODS: Qualitative in-depth interviews were conducted with 74 caregivers of a family member who had been receiving hospice care for at least 2 weeks. Interviews were tape recorded, transcribed, and coded for emergent themes using constant comparative analysis. RESULTS: End-stage caregiving was characterized in the sample as (1) comprehension of terminality (the interrelationship of information, physical and cognitive decline, and personality change and role losses), (2) near-acute care, (3) executive functions, and (4) final decision making. The comprehension of terminality emerged from three interrelated experiences: receiving and assimilating concrete information about the illness, observing the progression of the disease, and observing the personality change and role loss. The primary stressors (unique end-stage caregiving tasks) were providing near-acute care, assuming an executive function, and beginning and final decision making. The secondary stressors were family role conflict, work conflict, and financial strain. Resources, such as intrinsic and extrinsic religious and faith practices and social support, were identified. Negative outcomes included intense emotional responses, and positive outcomes included heightened development of meaning making. CONCLUSION: The findings suggest that palliative care professionals have important opportunities to provide information and support to family caregivers during the final stages of the patient's terminal illness.

Neuropathic pain: implications for the surgeon.

Pharmacologic therapy for neuropathic pain is based on an evolving understanding of its underlying mechanisms, and often requires a patient,methodical sequence of trials that include the "four As": analgesics,antidepressants, anticonvulsants, and antiarrhythmics. Critical for success is a willingness to stay engaged with the patient to evolve a mutually acceptable plan and goals of care with realistic outcomes that emphasize symptom control and maximization of function. Such management is within the capabilities of surgeons for most patients, whereas the use of consultation and interdisciplinary supportive interventions from comprehensive pain management centers, if available, is helpful in more difficult cases.

Surgical palliative care.

Surgery has always played a pivotal role in care of the patient with cancer, independent of treatment intent. Recent advances have expanded that role, not only in terms of modalities available, but more broadly in terms of the expectations of the surgeon as physician involved in the interdisciplinary care of the patient with symptomatic, incurable disease.