When does early palliative care influence aggressive care at the end of life?

BACKGROUND: Early palliative care improves patient quality of life and influences cancer care. The time frame of early has not been established. Eight quality measures reflect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018, through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). METHODS: Patients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 30-90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with confidence intervals (CI) was reported as a measure of effect size. A p value ≤ 0.05 was considered significant. RESULTS: 1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). Seventy-one percent had a palliative care consult, 26% completed AD, and 888 (51.4%) had at least one indicator of ACEOL. The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. ADs completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care initiated at 30 days was associated with a greater risk of ACEOL (OR 5.32, 95% CI 3.94-7.18) and initiated between 30 and 90 days (OR 1.39, 95% CI 1.07-1.80) compared to no palliative care but was associated with reduced chemotherapy as an indicator of ACEOL when > 90 days (OR 0.46, 95% CI 0.38-0.57) before death. DISCUSSION: Completed ADs were associated with reduced chemotherapy in the last 30 days of life and reduced ICU admissions. This may reflect goals of care and end-of-life discussions and transition of care to comfort measures. Palliative care paradoxically when initiated within 90 days before death was associated with greater ACEOL compared to no palliative care. This may be due to consultation late in the course of illness with a focus on crisis management in patients frequently utilizing the health care system. There is an associated reduction in the use of chemotherapy in the last 30 days of life if palliative care is consulted 90 days prior to death. CONCLUSIONS: An initial palliative care consult greater than 90 days before death and ADs completed at any time during the disease trajectory was associated only with reduced chemotherapy in the last 30 days of life compared with no palliative care among the 7 ACEOL indicators. ADs were associated with reduced ICU admissions. Most palliative care consults occurred within 90 days of death and a palliative care consult within 90 days of death is not an optimal utilization of services.

The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs.

BACKGROUND: Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month's costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL. METHOD: Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000. DISCUSSION: ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs. CONCLUSION: Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.

How Should We Assess Pain: Do Patients Prefer a Quantitative or Qualitative Scale? A Study of Patient Preferences.

BACKGROUND: Pain perception is a subjective experience and is influenced by a variety of factors. Pain assessment tools, included the numeric pain rating scale (NRS) and the visual analog scale (VAS). A VAS qualitative (VASQ) scale asks patients their current pain level along a continuum of "Good Day," "Average Day," or "Bad Day." We had patients complete both scales and asked them their preference and reason for their choice. METHODS: We identified patients 18 years of age and older, seen by Palliative medicine at Geisinger, who had cancer-associated pain of at least one-month duration. Patients filled out the study questionnaire composed of 2 questions. Characteristics of patients who preferred the VASQ were compared to those who preferred the NRS using a 2-sample t tests or Wilcoxon rank-sum tests and Pearson χ2 or Fisher exact tests. The relationship between the NRS and the VASQ used the Pearson correlation coefficient. RESULTS: One hundred forty-six patients completed the questionnaire, 52.1% were female; 63.7% preferred the NRS, 31.5% preferred the VASQ. Patients who preferred the NRS reported a higher NRS rating than patients who preferred the VASQ (mean NRS rating of 6.0 compared to 5.3) but the difference was not statistically significant (P = .1531). Visual analog scale qualitative ratings were higher among patients who preferred the NRS, but the difference was not statistically different (mean rating of 5.2 vs 4.8, P = .3669). CONCLUSION: Patients preferred the NRS over VASQ for pain assessment. Patients tend to rate their pain at a higher level when using NRS compared to VASQ.

Reasons to avoid fentanyl.

Fentanyl has been FDA approval as an analgesic since 1968 and multiple different fentanyl preparations have been developed over the years. Little was known about it is clinical utility defined by risks and benefits until recently. Present commercially available preparations are easily tampered and nonpharmacologic fentanyl has become the major cause of opioid deaths in the United States. This state-ofthe-art review will discuss fentanyl pharmacology, utility, safety and abuse.

Cancer-Related Fatigue: Perception of Effort or Task Failure?

CONTEXT: Patient's rating of perceived effort (RPE) is used to assess central fatigue. Cancer-related fatigue (CRF) is believed to be of central origin. The increased RPE with a motor task, such as the Finger-Tapping Test (FTT), can easily be measured in the clinical setting. OBJECTIVES: To correlate the FTT, RPE and the Brief Fatigue Inventory (BFI) rated fatigue severity in patients with cancer. METHODS: Subjective fatigue was assessed in adult patients with cancer by the BFI. Participants performed a modified FTT with the index finger of the dominant hand: 15 seconds × 2, 30 seconds × 2, and 60 seconds × 2 with 1 minute of rest between each time trial. Rating of perceived effort at the end of task was measured by the Borg 10 scale. EXCLUSIONS: Brain metastasis, history of brain radiation, Parkinson disease, Huntington Chorea, multiple sclerosis, delirium, and depression. Pearson correlation coefficients were used to describe the relationships between BFI, FTT, and Borg 10 scale. RESULTS: Thirty patients participated. Mean age was 56.2. Sixteen were females (53.3%). The mean BFI mean was 4.1, median 4.4. Tapping rate did not correlate with fatigue severity. The RPE correlated with the mean BFI: r s 0.438, P = .0155. These correlations persisted after adjustment for age. CONCLUSION: An increased RPE in the absence of task failure suggests that the origin of CRF is central. The performance of an FTT with RPE helps to improve our understanding of fatigue in the clinical setting.

Ginseng: A Qualitative Review of Benefits for Palliative Clinicians.

Ginseng has been used for centuries to treat various diseases and has been commercially developed and cultivated in the past 300 years. Ginseng products may be fresh, dried (white), or dried and steamed (red). Extracts may be made using water or alcohol. There are over 50 different ginsenosides identified by chromatography. We did an informal systematic qualitative review that centered on fatigue, cancer, dementia, respiratory diseases, and heart failure, and we review 113 studies in 6 tables. There are multiple potential benefits to ginseng in cancer. Ginseng, in certain circumstances, has been shown to improve dementia, chronic obstructive pulmonary disease, and heart failure through randomized trials. Most trials had biases or unknown biases and so most evidence is of low quality. We review the gaps in the evidence and make some recommendations regarding future studies.

The Potential Benefits of Palmitoylethanolamide in Palliation: A Qualitative Systematic Review.

Palmitoylethanolamide (PEA) is a nutraceutical endocannabinoid that was retrospectively discovered in egg yolks. Feeding poor children with known streptococcal infections prevented rheumatic fever. Subsequently, it was found to alter the course of influenza. Unfortunately, there is little known about its pharmacokinetics. Palmitoylethanolamide targets nonclassical cannabinoid receptors rather than CB1 and CB2 receptors. Palmitoylethanolamide will only indirectly activate classical cannabinoid receptors by an entourage effect. There are a significant number of prospective and randomized trials demonstrating the pain-relieving effects of PEA. There is lesser evidence of benefit in patients with nonpain symptoms related to depression, Parkinson disease, strokes, and autism. There are no reported drug-drug interactions and very few reported adverse effects from PEA. Further research is needed to define the palliative benefits to PEA.

Treating Chronic Pain: An Overview of Clinical Studies Centered on the Buprenorphine Option.

The buprenorphine receptor binding profile is unique in that it binds to all three major opioid receptors (mu, kappa, delta), and also binds to the orphan-like receptor, the receptor for orphanin FQ/nociceptin, with lower affinity. Within the mu receptor group, buprenorphine analgesia in rodents is dependent on the recently discovered arylepoxamide receptor target in brain, which involves a truncated 6-transmembrane mu receptor gene protein, distinguishing itself from morphine and most other mu opioids. Although originally designed as an analgesic, buprenorphine has mainly been used for opioid maintenance therapy and only now is increasingly recognized as an effective analgesic with an improved therapeutic index relative to certain potent opioids. Albeit a second-, third-, or fourth-line analgesic, buprenorphine is a reasonable choice in certain clinical situations. Transdermal patches and buccal film formulations are now commercially available as analgesics. This review discusses buprenorphine pharmacodynamics and pharmacokinetics, use in certain populations, and provides a synopsis of systematic reviews and randomized analgesic trials. We briefly discuss postoperative management in patients receiving buprenorphine maintenance therapy, opioid equivalence to buprenorphine, rotations to buprenorphine from other opioids, and clinical relevance of buprenorphine-related QTc interval changes.

What Parenteral Opioids to Use in Face of Shortages of Morphine, Hydromorphone, and Fentanyl.

Parenteral potent opioid availability is becoming an issue in acute pain management. Two opioids, nalbuphine and buprenorphine, are available which can be substituted for hydromorphone, fentanyl, and morphine. There are advantages and disadvantages in using these 2 opioids which are discussed, and potential dosing strategies are outlined.

Looking both ways before crossing the street: Assessing the benefits and risk of opioids in treating patients at risk of sleep -disordered breathing for pain and dyspnea.

Opioids adversely influence respiration in five distinct ways. Opioids reduce the respiratory rate, tidal volume, amplitude, reflex responses to hypercapnia and hypoxia, and arousability related necessary for respiratory adaptive responses. Opioids cause impairment of upper pharyngeal dilator muscles leading to obstructive apnea. Opioids cause complex sleep disordered breathing (SDB) consisting of central sleep apnea and obstructive sleep apnea. Clinically opioids worsen pre-existing SDB. Recent studies have shown increased morbidity and mortality in patients receiving opioids for chronic noncancer pain and chronic obstructive pulmonary disease, which appear to be related to cardiovascular events, not overdose. Both patient populations are at risk for sleep disordered breathing and increased risk for adverse cardiovascular events on opioids for dyspnea or pain. This review discusses the influence of opioids on respiration and SDB and will review the adverse respiratory and cardiovascular effects of opioid use in at risk populations. Recommendations regarding management will follow as a summary.