Polypharmacy in the terminal stage of cancer.

PURPOSE: This study aims to determine the numbers of patients with advanced cancer receiving polypharmacy at the end of their lives and analyze differences in drug prescription at a general oncology ward and a dedicated palliative care ward. METHODS: A retrospective single-center cohort study at a university hospital with a large cancer center was conducted. The charts of 100 patients who had died because of advanced cancer were reviewed; data concerning sociodemographic variables and medications were collected at four predefined time points (9, 6, 3, 0 days before death). RESULTS: Nine days before death, polypharmacy was registered in 95 % of patients; they had prescriptions for 11 (9-13) different medications per day (median, IQR). Although this number dropped significantly, on the last day as many as 61 % of the patients were still taking more than 4 drugs (median 6.5, IQR 4-9). No significant difference was noted between the oncology ward and the palliative care ward. Polypharmacy was largely dependent on the patients' ECOG performance status as well as the type of ward, the number of days before death, and age. It was not influenced by gender, the duration of hospital stays, and the devices facilitating drug administration. The medications fulfilled the requirements of palliative care in the majority of patients; 90 % received treatment for pain and anxiety. Patients treated at the palliative ward received more opioids and psychoactive drugs while those at the oncology ward received more anti-cancer drugs and fluids. CONCLUSIONS: Polypharmacy still is a problem in the large majority of patients with terminal cancer. Further studies should be focused on the patients' quality of life, drug interactions, and adverse events.

Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria.

BACKGROUND: There is limited data on the use of thromboprophylaxis in patients with advanced cancer. We therefore aimed to study the practice of thromboprophylaxis in palliative care units in Austria. METHODS: We monitored use, indication, and contraindications to thromboprophylaxis in 134 patients hospitalized in 21 palliative care units in a prospective, cross-sectional study. RESULTS: Forty-seven percent of patients were on low molecular weight heparin on the day of the study for primary or secondary thromboembolism. Thromboprophylaxis had been withdrawn in 18% of the patients upon admission to the palliative care unit. Contraindications for thromboprophylaxis were present in 27% of all patients. Cancer was present in 86% of the patients. The use of thromboprophylaxis was similar in cancer patients and in non-cancer patients (49% vs. 42%). Contraindications for thromboprophylaxis were present in 24% of all cancer patients. Significantly more bedridden cancer patients had contraindications for prophylaxis when compared with mobile cancer patients (35% vs. 16%; p = 0.03). Low performance status was by far the most frequent contraindication among these patients (89%). Seventy-one percent of all bedridden cancer patients were treated in accordance with common guidelines for thromboprophylaxis when contraindications were taken into account. Eighty-seven percent of patients who had been involved in decision making opted for getting prophylaxis. CONCLUSIONS: Our data reveal that about half of all cancer patients in palliative care units are treated with thromboprophylaxis. Low performance status was the most frequent contraindication for thromboprophylaxis.

[Vertigo as a symptom of psychosocial pain]. / Schwindel als Symptom psychosozialen Schmerzes.

Vertigo in a patient with end stage lung cancer challenges the caring team. No relief can be achieved by various treatment attempts. In a retrospective analysis it turns out that the physical symptom of vertigo makes up for psychosocial pain. Causes for this reaction can be found in the patient's history and deal with solitude and loss in a wider sense. Finding out what means quality of life to an individual patient leads to general ideas about human needs. Considerations about the best place to stay for a dying person need to be merged with the options a medical system offers.

Low dose acetylsalicylic acid and shedding of microparticles in vivo in humans.

BACKGROUND: Microparticles (MPs) have procoagulant properties as shown in vitro and in animal models. Their role in haemostatic system activation at the site of a vascular injury in vivo in humans has not been studied. MATERIAL AND METHODS: In a prospective randomized crossover study, 13 healthy volunteers were given 100 mg acetylsalicylic acid or placebo daily for 7 days. Number and cellular origin, expression of tissue factor (TF) and phosphatidylserine on MPs, and platelet and coagulation activation markers [beta-thromboglobulin (beta-TG), prothrombin fragment f1.2 (f1.2)] were measured in venous blood and in blood from a vascular injury (shed blood) by flow cytometry and immunoassays, respectively. RESULTS: The number of MPs was significantly higher in shed blood than in venous blood. The majority of MPs were platelet derived. The expression of TF on MPs was low, but higher in shed blood than in venous blood. TF positive MPs were significantly higher in shed blood, which was due to an increase of MPs from platelets (PMPs). In shed blood, the number of TF expressing platelet-derived MPs correlated with beta-TG, but not with f1.2. Low dose acetylsalicylic acid did not affect shedding of PMPs, neither in venous blood nor in shed blood. CONCLUSIONS: The release of PMPs locally at the site of platelet plug formation in humans indicates a possible role of MPs for haemostatic system activation in vivo. Low dose acetylsalicylic acid might not be strong enough to suppress shedding of PMPs in the microcirculation.

Attitudes towards palliative care in primary metastatic cancer: a survey among oncologists.

Oncologists differ widely in their attitudes towards palliative care and services. These attitudes depend on a number of individual and society-based variables. It is recommended that palliative care be started early in the disease trajectory of patients with a life-threatening disease but in Austria we lack data on oncologists' adherence to this recommendation. We surveyed 785 oncologists in Austria by presenting the clinical course of a hypothetical patient with primary metastatic breast cancer from diagnosis until death. The majority of oncologists would involve palliative care services when the patient's Karnofsky index (KI) was < 50, and hospice services when the KI was < 40. Special training in palliative care was significantly associated with early use of hospice services. Reasons for not involving palliative care and hospice services earlier than indicated were systematically evaluated and included, among others, "fear of destroying the patient's hopes" (36% of respondents with regard to palliative services, 57% with regard to hospices). Overall, 67% of the oncologists would inform the patient about the malignant nature of her disease and the anticipated limitation of her life expectancy at the time of diagnosis. Issuing an advance directive would be discussed by only 25% at that time. Our data show that oncologists involve palliative care services at an advanced stage of disease in patients with primary metastatic cancer and that information about malignancy and the incurable nature of the disease is not uniformly provided at the time of diagnosis.

Attitudes of patients with malignancies towards completion of advance directives.

AIM: The purpose of advance directives (AD) is to preserve the patient's autonomy at the end of his/her life. In a cohort study, we investigated attitudes towards AD in hospitalized patients with malignant disease. MATERIALS AND METHODS: All patients were informed about the basic features of AD in a standardized manner by a single independent physician. One hundred and eight (39 women, 69 men; mean age 56.6 +/- 14.9 years) of 140 invited patients completed the study. MAIN RESULTS: Five percent of patients (5/108) already had an AD; 85% (92/108) did not wish to issue an AD. "Full confidence in physicians" (22%) and "not important for me at the moment" (15%) were the most frequently stated reasons for not issuing an AD. Only 10% (11/108) of patients decided to complete an AD. Their decision was not related to a specific diagnosis or a number of socio-demographic variables that were studied. Patients who decided in favor of an AD had significantly higher Hospital Anxiety and Depression Scale (HADS-D) score than those who decided against it (HADS-D, 8.3 +/- 5.0 vs.5.8 +/- 4.1, p = 0.035). The patients' HADS depression score was negatively associated with their Karnofsky index (r = -0.232, p = 0.017). CONCLUSIONS: Our data reveal a scarce demand for AD in our population of hospitalized cancer patients. Patients who wanted to issue an AD had a high HADS-D, which is associated with a low performance status.

The emotional impact of genetic testing and aspects of counseling prior to prescription of oral contraceptives.

BACKGROUND: Oral contraceptives increase the thrombotic risk in women with factor V Leiden. Emotional aspects of genetic testing prior to the prescription of oral contraceptives (OC), aspects of counseling and referral patterns are widely unknown. STUDY DESIGN: Two hundred forty-seven women with and 132 women without factor V Leiden were interviewed by questionnaire. RESULTS: One hundred sixty-one women (65%) with factor V Leiden and 63 (48%) with wild-type factor V responded. One hundred seventy-one women (76%) reported being emotionally disturbed by genetic testing. Eighty percent of women with factor V Leiden and 16% of women with wild-type factor V were discouraged from OC use. Three percent of women with factor V Leiden were encouraged to take OC. Forty-one percent of women with factor V Leiden used at least one hormone contraceptive method after diagnosis. Only 46 women (29%) with factor V Leiden were counseled about the relevance of the mutation in case of pregnancy. CONCLUSIONS: Testing for factor V Leiden has considerable emotional impact. Recommendations after testing are not consistently driven by the test result.

Use of thromboprophylaxis in palliative care patients: a survey among experts in palliative care, oncology, intensive care, and anticoagulation.

Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovsky's index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovsky's index of 20 and by 85% when Karnovsky's index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

Family history for venous thromboembolism and the risk for recurrence.

PURPOSE: The relevance of a family history for venous thromboembolism with regard to the likelihood for recurrence is unknown. SUBJECTS AND METHODS: We studied 826 patients for an average of 36 months after a first unprovoked venous thromboembolism and withdrawal of oral anticoagulation. Patients with cancer, lupus anticoagulant, or deficiency of antithrombin, protein C, or protein S were excluded. The study endpoint was objective evidence of recurrent symptomatic venous thromboembolism. RESULTS: Recurrence for venous thromboembolism was recorded in 23 of 190 patients (12.1%) with a family history (at least one affected first-degree family member) and in 79 of 636 patients (12.4%) without familial thrombosis (relative risk for recurrence 1.0; 95% confidence interval, 0.7-1.6; P=.9). At 5 years, the likelihood for recurrence was 20% among patients with a family history for venous thromboembolism and 18% among those without a family history for venous thromboembolism (P=.9). Risk determinants for venous thromboembolism including factor V Leiden, factor II G20210A, and high factor VIII were not statistically different between the 2 groups. CONCLUSION: A family history for venous thromboembolism does not segregate patients into high- or low-risk categories and is not suitable to identify patients at increased risk for recurrent venous thromboembolism.