Effects of Anticholinergics on Death Rattle: A Systematic Review and Network Meta-Analysis.

Background: Anticholinergics have been used to treat death rattle (DR) in dying patients with palliative care. However, the effect of anticholinergics is still controversial. No quantitative summary of their effects is reported. Objective: This study aimed to systematically review and quantitatively synthesize the effect of anticholinergics on DR treatment and prophylaxis. Design: A systematic search was performed in the electronic databases (PubMed, Embase®, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) from inception to October 2021. Studies conducted to determine the effect of anticholinergics compared with other anticholinergics or placebo on noise reduction score in dying patients were included. A network meta-analysis was performed for DR treatment. The effect of anticholinergics at four hours was assessed. A pairwise meta-analysis was performed for DR prophylaxis. Results: A total of nine studies were included with 1103 patients. Six studies were randomized controlled trials, and three studies were cohort studies. Seven studies were conducted for DR treatment, while two studies were conducted for DR prophylaxis. For DR treatment, no statistically significant difference was observed between each anticholinergic (hyoscine hydrobromide, hyoscine butyl bromide, atropine, and glycopyrrolate) and placebo and among any anticholinergics. However, the surface under cumulative ranking curve indicated that hyoscine butyl bromide had the highest surface under the cumulative ranking curve (SUCRA) with 71.3%. For DR prophylaxis, the relative risk of DR occurrence for hyoscine butyl bromide was 0.23 (0.04, 1.18; I2 = 84.5%) compared with no treatment. Conclusion: This study showed no strong evidence of the regular use of anticholinergics for DR treatment. In addition, hyoscine butyl bromide appears to have a high potential for DR prophylaxis.

A study of the factors associated with emergency department visits in advanced cancer patients receiving palliative care.

PURPOSE: Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients. METHODS: A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16-100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value < 0.15 from the univariate logistic regression analysis were included in the multiple logistic regression analysis. RESULTS: Among a total of 227 patients, 93 visited the ED and 134 did not. Mean age was 65.5 years. Most prevalent cancers were colorectal (18.5%), lung (16.3%), and hepatobiliary (11.9%). At the end, 146 patients died, 45 were alive, nine were referred to other programs, and 27 were lost to follow-up. In univariate logistic regression analysis, patients with > 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p-value 0.01) were less likely to attend the ED. In contrast, PPS 50-90% (OR 2.02; 95%CI 1.18, 3.47; p-value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p-value 0.01) and PPS 50-90% (OR 2.62; 95%CI 1.44, 4.79; p-value 0.01). CONCLUSIONS: There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.

A study to translate and validate the Thai version of the Victoria Respiratory Congestion Scale.

PURPOSE: Few clinical tools are available to objectively evaluate death rattles in palliative care. The Victoria Respiratory Congestion Scale (VRCS) was adapted from the Back's scale, which has been widely utilized in research and clinical practice. The VRCS will be translated into Thai and research will be conducted to determine its validity and reliability in assessing death rattles in palliative care. METHODS: Two qualified language specialists converted the original tool into Thai and then back to English. Between September 2021 and January 2022, a cross-sectional study was undertaken at a palliative care unit at Ramathibodi Hospital to determine the Thai VRCS's validity and reliability. Two evaluators independently assessed the volume of secretion noises using the Thai VRCS. The criterion-related validity of VRCS was determined by calculating the correlation between the sound level obtained with a standard sound meter and the VRSC scores using Spearman's correlation coefficient method. To assess inter-rater reliability and agreement measurement on ratings, we utilized a two-way random-effects model with Cohen's weighted kappa agreement. RESULTS: Forty patients enrolled in this study with a mean age of 75.3 years. Fifty-five percent had a cancer diagnosis. Spearman's rho correlation coefficient was found to be 0.8822, p < 0.05, indicating a highly significant link. The interrater reliability analysis revealed that the interrater agreement was 95% and the Cohen's weighted kappa agreement was 0.92, indicating near-perfect agreement. CONCLUSIONS: Thai VRCS demonstrated excellent criteria-related validity and interrater reliability. Using the Thai VRCS to assess adult palliative care patients' death rattles was recommended.

Perspective and conception of Thai gynecologic oncologists in palliative care.

BACKGROUND: Palliative care evidently increases the quality of life among the patients with advanced cancer. However, there are very few studies on the aspects of the physicians' ideas, conceptions, or the effects of their ideas in palliative care quality, especially in Asian countries. This study aimed to evaluate the conception and perspective on palliative care in Thai gynecologic oncologists. METHODS: The online survey was distributed to all certificated Thai gynecologic oncologists. The survey could be accessed via working email address, hyperlink, or QR code during May 2020 and January 2021. A 5-point Likert scale captured the perspectives and concepts of palliative care. The association between respondents' characteristics and their choices of content in palliative care, together with their decision making in specified clinical scenarios was analyzed. RESULTS: A total of 207 completed surveys from 320 Thai gynecologic oncologists were received (64.69% participation rate). They prospected a willingness to give the advices to both patients and their families (85.50%), and strongly agreed to introduce palliative care in any stage of cancer at the time of diagnosis (75.80%). The numbers of their palliative cases per year were 5-20 (57.97%) and the palliative care teams were available in their hospitals. They decided to offer early palliative care and do-not-resuscitate, especially for the elders, or patients with advance stages, or recurrent disease. We found that gynecologic oncologists who previously experienced a palliative care training did not show any difference in decision making in specified clinical scenarios, compared with who did not. CONCLUSIONS: Thai gynecologic oncologists responded to the conceptions and perspectives in palliative care. Their concepts of early and willingness to offer a palliative care especially in the elders, advanced stage, or recurrent patients were proven, regardless of the experience in palliative care training.

The Accuracy of the Edmonton Symptom Assessment System for the Assessment of Depression in Patients With Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Depression is a common health problem among patients with cancer. The Edmonton Symptom Assessment System (ESAS) is one of many tools that have been used to evaluate depression in these patients. Nevertheless, the diagnostic performance and the appropriate cutoff point of the ESAS for the assessment of depression in these patients have varied in the studies. PURPOSE: To determine the diagnostic accuracy and the optimal cutoff point for the ESAS for the assessment of depression in patients with cancer. DATA SOURCES: PubMed, Scopus, CINAHL, and Cochrane library databases from inception to September 18, 2016. STUDY SELECTION: Paired reviewers independently screened abstracts and full-text articles for all cross-sectional studies published in English and compared these with the ESAS in the depression (ESAS-D) subscale with reference to standard tests for the assessment of depression. DATA EXTRACTION: Two reviewers serially abstracted the data and independently assessed the risk of bias by using the Quality Assessment of Diagnostic Accuracy Studies 2. DATA SYNTHESIS: A total of 6 studies were eligible for review. Our meta-analysis showed the optimal cutoff point of the ESAS-D ≥ 4, with pooled sensitivity and specificity at 53% (95% confidence interval [CI]: 38%-67%) and 90% (95% CI: 82%-94%), respectively. The positive likelihood ratio and diagnostic odds ratio of the ESAS-D ≥ 4 were 5.2 (95% CI: 3.1-8.6) and 10 (95% CI: 5-19). There was a high degree of heterogeneity between the studies ( P value <.001, I2 = 96%). CONCLUSION: We suggest that an ESAS-D ≥ 4 could be used to detect possible cases of depression in patients with cancer. Registration: Our study protocol was registered with the International Prospective Register of Systematic Reviews on October 4, 2016, and was last updated on January 11, 2017 (registration number CRD42016048288).

A Study of the Association Between Multidisciplinary Home Care and Home Death Among Thai Palliative Care Patients.

PURPOSE: Many terminally ill patients would prefer to stay and die in their own homes, but unfortunately, some may not be able to do so. Although there are many factors associated with successful home deaths, receiving palliative home visits from the multidisciplinary care teams is one of the key factors that enable patients to die at home. Our study was aimed to find whether there was any association between our palliative home care program and home death. METHODS: A retrospective study was conducted in the Department of Family Medicine at Ramathibodi Hospital between January 2012 and May 2014. All of the patients who were referred to multidisciplinary palliative care teams were included. The data set comprised of patient's profile, disease status, functional status, patient's symptoms, preferred place of death, frequency of home visits, types of team interventions, and patient's actual place of death. Multiple logistic regression was applied in order to determine the association between the variables and the probability of dying at home. RESULTS: A total of 142 patients were included into the study. At the end of the study, 50 (35.2%) patients died at home and 92 (64.8%) patients died in the hospital. The multivariate logistic regression analysis demonstrated a strong association between multidisciplinary home care and home death (odds ratio 6.57, 95% confidence interval [CI] 2.48-17.38). CONCLUSION: Palliative home care was a significant factor enabling patients who want to die at home. We encourage health policy makers to promote the development of community-based palliative care programs in Thailand.

The association between different opioid doses and the survival of advanced cancer patients receiving palliative care.

BACKGROUND: Concerns that opioids may hasten death can be a cause of the physicians' reluctance to prescribe opioids, leading to inadequate symptom palliation. Our aim was to find if there was an association between different opioid doses and the survival of the cancer patients that participated in our palliative care program. METHODS: A retrospective study was conducted at Ramathibodi Hospital, Bangkok between January 2013 and December 2015. All of the cancer patients that were referred to palliative care teams by their primary physicians were included in the study. The study data included the patients' demographics, disease status, comorbidities, functional status, type of services, cancer treatments, date of consultation, and the date of the patient's death or last follow-up. The information concerning opioid use was collected by reviewing the medical records and this was converted to an oral morphine equivalent (OME), following a standard ratio. The time-varying covariate in the Cox regression analysis was applied in order to determine the association between different doses of opioids and patient survival. RESULTS: A total of 317 cancer patients were included in the study. The median (IQR) of the OME among our patients was 6.43 mg/day (0.53, 27.36). The univariate Cox regression analysis did not show any association between different opioid doses (OME ≤ 30 mg/day and > 30 mg/day) and the patients' survival (p = 0.52). The PPS levels (p < 0.01), palliative care clinic visits (HR 0.32, 95%CI 0.24-0.43), home visits (HR 0.75, 95%CI 0.57-0.99), chemotherapy (HR 0.32, 95%CI 0.22-0.46), and radiotherapy (HR 0.53, 95%CI 0.36-0.78) were identified as factors that increased the probability of survival. CONCLUSIONS: Our study has demonstrated that different opioid doses in advanced cancer patients are not associated with shortened survival period.

Comparison of the Constipation Assessment Scale and plain abdominal radiography in the assessment of constipation in advanced cancer patients.

CONTEXT: Constipation is a distressing condition for advanced cancer patients and is frequently underdiagnosed. OBJECTIVES: The primary objective of this study was to determine if a strong correlation existed between the use of the Constipation Assessment Scale (CAS) and a plain abdominal radiograph in the interpretation of constipation in patients with advanced cancer. The secondary aim of the study was to compare the plain film radiographic constipation scores among three palliative medicine physicians. METHODS: The study was a prospective cross-sectional study of 50 advanced cancer patients admitted to a tertiary palliative care unit. These patients completed the CAS shortly after their admission to the unit. Around the same time, they underwent a flat plate of abdomen that was scored from 0 to 12, based on the amount of stool in the colon, by three palliative medicine physicians who were blinded to the CAS results and each other's radiographic interpretations. Kendall Tau correlation coefficient was used to estimate and test the correlations between the CAS and radiographic constipation scores. RESULTS: There was no concordant correlation between the CAS scores and each physician's radiographic constipation score. There also was no concordant correlation between the CAS score and the combined radiographic constipation scores of the three palliative medicine physicians (Kendall Tau coefficient=0.04; P=0.72). The degree of correlation between the radiographic constipation scores from the three palliative medicine physicians was moderate. CONCLUSION: Our study failed to yield a strong correlation between the CAS and the plain abdominal radiographic scores for constipation completed by three palliative medicine physicians. It is advisable that constipation in advanced cancer patients be assessed both clinically and radiographically.