Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study.

Essentials Bleeding incidence as hemorrhagic risk factors are unknown in palliative care inpatients. We conducted a multicenter observational study (22 Palliative Care Units, 1199 patients). At three months, the cumulative incidence of clinically relevant bleeding was 9.8%. Cancer, recent bleeding, thromboprophylaxis and antiplatelet therapy were independent risk factors. SUMMARY: Background The value of primary thromboprophylaxis in patients admitted to palliative care units is debatable. Moreover, the risk of bleeding in these patients is unknown. Objectives Our primary aim was to assess the bleeding risk of patients in a real-world practice setting of hospital palliative care. Our secondary aim was to determine the incidence of symptomatic deep vein thrombosis and to identify risk factors for bleeding. Patients/Methods In this prospective, observational study in 22 French palliative care units, 1199 patients (median age, 71 years; male, 45.5%), admitted for the first time to a palliative care unit for advanced cancer or pulmonary, cardiac or neurologic disease were included. The primary outcome was adjudicated clinically relevant bleeding (i.e. a composite of major and clinically relevant non-major bleeding) at 3 months. The secondary outcome was symptomatic deep vein thrombosis. Results The most common reason for palliative care was cancer (90.7%). By 3 months, 1087 patients (91.3%) had died and 116 patients had presented at least one episode of clinically relevant bleeding (fatal in 23 patients). Taking into account the competing risk of death, the cumulative incidence of clinically relevant bleeding was 9.8% (95% confidence interval [CI], 8.3-11.6). Deep vein thrombosis occurred in six patients (cumulative incidence, 0.5%; 95% CI, 0.2-1.1). Cancer, recent bleeding, antithrombotic prophylaxis and antiplatelet therapy were independently associated with clinically relevant bleeding at 3 months. Conclusions Decisions regarding the use of thromboprophylaxis in palliative care patients should take into account the high risk of bleeding in these patients.

[Development of a tool for withholding and withdrawing life-sustaining treatment in the emergency room]. / Élaboration et validation d'une fiche d'aide à la décision de limitation ou d'arrêt des traitements aux urgences.

OBJECTIVES: Active treatment withholding and withdrawing decisions in the emergency room (ER) must be taken collegially according to ethical and juridical statements. Specific tools can support this process and our main goal was to create and validate such a tool. METHOD: We created a first version of a tool to help for treatment withholding and withdrawing decisions inspired by similar documents from literature. Every item of this tool was then assessed by a group of experts (ER physicians and nurses) using the Delphi method to reach a consensus. RESULTS: Thirty-four experts from eleven ER (academic, regional centre) were included and participate to the first round and twenty-seven to the second round. From the eighty-two-item tool, sixty-five items reach a consensus during these two rounds and were kept to constitute the final version of the tool. CONCLUSION: We have been able to create a tool to help for treatment withholding and withdrawing decisions adapted to the guidelines for end of life patient's management in the ER. This tool has been validated using a Delphi method by a group of experts from different centres. This multicentre validation will help for the diffusion and use of this tool in the different ER of the Rhône-Alpes region.

[Palliative care for patients with heart failure]. / Soins palliatifs chez les patients en insuffisance cardiaque terminale.

PURPOSE: Heart failure is a common disease and its progression to end-stage heart failure is responsible of high mortality. The aim of this retrospective study was to assess the access to integrated palliative care to the usual management, 6 months prior to their death, and especially during the last hospitalization. PATIENTS AND METHODS: A retrospective study was performed in patients who died of heart failure in 2009 in two hospitals. The analysis was performed on 20 cases of each institution. The records of consecutive patients were included in an anti-chronological order from 31st December 2009. RESULTS: For their last hospitalization, 37 patients (93%) were hospitalized in emergency. Within 3 days prior to death, the most frequent symptoms were dyspnea (n=33, 82%), and pain (n=30, 75%). Therapeutic most frequently used were oxygen (n=31, 77%) and analgesics (n=30, 75%). No patient was seen by a psychologist. The decision to limit treatment for comfort care was reported for 24 patients (60%) and the median of the average time between the decision and death was 2 days (Q1-Q3, 1-5 days). CONCLUSION: Patients with terminal heart failure have many symptoms often requiring multidisciplinary care. This type of study relating practices shows that there is still a lot to do to integrate palliative care in the usual management of patients with heart failure.

Barriers to the development of palliative care in Western Europe.

UNLABELLED: The Eurobarometer Survey of the EAPC Task Force on the Development of Palliative Care in Europe is part of a programme of work to produce comprehensive information on the provision of palliative care across Europe. AIM: To identify barriers to the development of palliative care in Western Europe. METHOD: A qualitative survey was undertaken amongst boards of national associations, eliciting opinions on opportunities for, and barriers to, palliative care development. By July 2006, 44/52 (85%) European countries had responded to the survey; we report here on the results from 22/25 (88%) countries in Western Europe. ANALYSIS: Data from the Eurobarometer Survey were analysed thematically by geographical region and by the degree of development of palliative care in each country. RESULTS: From the data contained within the Eurobarometer, we identified six significant barriers to the development of palliative care in Western Europe: (i) lack of palliative care education and training programmes; (ii) lack of awareness and recognition of palliative care; (iii) limited availability of/knowledge about opioid analgesics; (iv) limited funding; (v) lack of coordination amongst services; and (vi) uneven palliative care coverage. CONCLUSION: Findings from the EAPC Eurobarometer Survey suggest that barriers to the development of palliative care in Western Europe may differ substantially from each other in both their scope and context and that some may be considered to be of greater significance than others. A number of common barriers to the development of the discipline do exist and much work still remains to be done in the identified areas. This paper provides a road map of which barriers need to be addressed.

Recomendaciones de la Asociación Europea de Cuidados Paliativos (EAPC) para el Desarrollo de la Especialidad en Medicina Paliativa. Informe del Grupo de Trabajo de la EAPC para la Formación Médica / No disponible

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Salivary gland dysfunction ('dry mouth') in patients with cancer: a consensus statement.

A group of interested professionals was convened to develop some evidence-based recommendations on the management of salivary gland dysfunction (SGD) in oncology patients. A Medline search was performed to identify the literature on SGD. The abstracts of all identified papers were read, and the full texts of all relevant papers were reviewed. The evidence was graded according to the Scottish Intercollegiate Guidelines Network grading system for recommendations in evidence-based guidelines. The summary of the main recommendations are: (1) patients with cancer should be regularly assessed for SGD (grade of recommendation - D); (2) the management of SGD should be individualised (D); (3) consideration should be given to strategies to prevent the development of radiation-induced SGD (C); (4) consideration should be given to treatment of the cause(s) of the SGD (C); (5) the treatment of choice for the symptomatic management of SGD is use of an appropriate saliva stimulant (C); (6) consideration should be given to prevention of the complications of the SGD (D); (7) consideration should be given to treatment of the complications of the SGD (D); and (8) patients with SGD should be regularly reassessed (D).

Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes.

BACKGROUND: The European Pain in Cancer survey sought to increase understanding of cancer-related pain and treatment across Europe. PATIENTS AND METHODS: Patients with all stages of cancer participated in a two-phase telephone survey conducted in 11 European countries and Israel in 2006-2007. The survey screened for patients experiencing pain at least weekly, then randomly selected adult patients with pain of at least moderate intensity occurring several times per week for the last month completed a detailed attitudinal questionnaire. RESULTS: Of 5084 adult patients contacted, 56% suffered moderate-to-severe pain at least monthly. Of 573 patients randomly selected for the second survey phase, 77% were receiving prescription-only analgesics, with 41% taking strong opioids either alone or with other drugs for cancer-related pain. Of those prescribed analgesics, 63% experienced breakthrough pain. In all, 69% reported pain-related difficulties with everyday activities; however, 50% believed that their quality of life was not considered a priority in their overall care by their health care professional. CONCLUSIONS: Across Europe and Israel, treatment of cancer pain is suboptimal. Pain and pain relief should be considered integral to the diagnosis and treatment of cancer; management guidelines should be revised to improve pain control in patients with cancer.

The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhône-Alpes' region.

A prospective survey of five palliative care units in the Rhône-Alpes region of France over a six-month period identified 13 requests for euthanasia (from the patient, family or both). The frequency of the request was low at 2.1% (of 611 patients). We have sought to establish the reasons for this request from the patient or family and the follow up of this request over time.