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.

Opioids and Chronic Pain: Where Is the Balance?

Chronic opioid therapy (defined as greater than 3 months on opioids) is a common practice for those with non-cancer pain, cancer survivors with treatment-related pain, and individuals with cancer undergoing disease-modifying therapy with a survival that can be for a year or more. Recent studies have found unique long-term toxicities with opioids which reduce the utility of opioid therapy in chronic pain. The risk of addiction, depression, central hypogonadism, sleep-disordered breathing, impaired wound healing, infections, cognitive impairment, falls, non-vertebral fractures, and mortality are increased in populations on long-term opioids. Factors associated with these risks are related to dose, duration of opioid therapy, type of opioid, and formula (long-acting, short-acting). This state-of-the-art review discusses the risks and benefits of chronic opioid therapy and strategies to increase utility and diminish risks to opioid therapy.

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.

The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation.

BACKGROUND: Inpatient palliative care may reduce length-of-stay, costs, mortality, and prevent readmissions. Timing of consultation may influence outcomes. The aim of this study was to explore the timing of consultation and its influences patient outcomes. METHOD: This retrospective study of hospital consultations between July 1, 2019 and December 31, 2019 compared patients seen within 72 hours of admission with those seen after 72 hours. Outcomes length of stay and mortality. Chi-square analyses for categorical variables and independent t-tests for continuous normally distributed variables were done. For nonparametrically distributed outcome variables, Wilcoxon rank sum test was used. For mortality, a time-to-event analysis was used. 30-day readmissions were assessed using the Fine-Gray sub-distribution hazard model. Multiple regression models were used, controlling for other variables. RESULTS: 696 patients were seen, 424 within 72 hours of admission. The average age was 73 and 50.6% were female. Consultation within 72 hours was not associated with a shorter stay for cancer but was for patients with non-cancer illnesses. Inpatient mortality and 30-days mortality were reduced but there was a higher 30-day readmission rate. DISCUSSION: Palliative consultations within 72 hours of admission was associated with lower hospital stays and inpatient mortality but increased the risk of readmission. Benefits were largely observed in patients followed in continuity. CONCLUSION: Early inpatient palliative care consultation was associated with reduced hospital mortality, 30-day mortality and length of stay particularly if patients were seen by palliative care prior to hospitalization.

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.

Opioid-Related Sleep-Disordered Breathing: An Update for Clinicians.

Opioids are an effective treatment for patients with intractable pain. Long-term administration of opioids for pain relief is being delivered by an increasing number of medical providers in the United States including primary care physicians and nonspecialists. One common complication of chronic opioid use is sleep-disordered breathing which can result in various morbidities as well as an increase in all-cause mortality. It is important for providers to understand the relationship between opioids and sleep-disordered breathing as well as methods to improve diagnosis and strategies for treatment. This review aims to update clinicians on the mechanism, diagnosis, and treatment of opioid-related sleep-disordered breathing in order to improve the quality of care for patients with chronic pain.

Tapering opioids: a comprehensive qualitative review.

This state-of-the-art review comprehensive covers the benefits and risks of tapering opioids. The review discusses opioid strategies and pitfalls that may occur during tapering. The purpose of this review is to expand the knowledge of clinicians regarding tapering opioids and equip them to be able to successfully reduce and stop opioid therapy when appropriate.

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.

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.

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.

Tsukamurella infection: a rare cause of community-acquired pneumonia.

A 79-year-old Asian man was admitted with community-acquired pneumonia. Antimycobacterial therapy was initiated when sputum smears revealed acid fast bacilli. The patient was, however, diagnosed to have pneumonia secondary to Tsukamurella spp. This is an exceedingly rare cause of pneumonia, especially in immunocompetent individuals. Clinical presentation, diagnosis and treatment strategies of Tsukamurella pneumonia are discussed with a literature review.