Update in palliative care--2011.

INTRODUCTION: The aim of this update is to summarize scientifically rigorous articles published in 2010 that serve to advance the field of palliative medicine and have an impact on clinical practice. METHOD: We conducted two separate literature searches for articles published between January 1, 2010 and December 31, 2010. We reviewed title pages from the Annals of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, JAMA, Journal of Clinical Oncology, JGIM, Journal of Pain and Symptom Management, Journal of Palliative Medicine, Lancet, New England Journal of Medicine, PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care). We also conducted a Medline search with the key words "palliative," "hospice," and "terminal" care. Each author presented approximately 20 abstracts to the group. All authors reviewed these abstracts, and when needed, full text publications. We focused on articles relevant to general internists. We rated the articles individually, eliminating by consensus those that were not deemed of highest priority, and discussed the final choices as a group. RESULTS: We first identified 126 articles with potential relevance. We presented 20 at the annual SGIM update session, and discuss 11 in this paper.

Breaking down Silos to improve the health of older adults: The case for medicare to cover home safety renovations.

The ageing population is increasing the financial strain on the United States health care system, and society may be underinvesting in the place-based determinants of elderly health. The leading cause of injury for older Americans is falls in the home, resulting in more deaths than any other injury, as well as a significant portion of Medicare spending. While medical interventions have yielded mixed results, home safety renovations have been shown to be a cost-effective strategy to enable senior citizens to "age in place" safely, with the health care savings outweighing the upfront investment. Conservative projections demonstrate that Medicare can undertake this investment in home safety renovations with less than 2 percent of its budget, while breaking down the silos that unnecessarily encircle health and housing.

Update in Hospital Palliative Care: Symptom Management, Communication, Caregiver Outcomes, and Moral Distress.

BACKGROUND: Updated knowledge of the palliative care (PC) literature is needed to maintain competency and best address the PC needs of hospitalized patients. We critiqued the recent PC literature with the highest potential to impact hospital practice. METHODS: We reviewed articles published between January 2016 and December 2016, which were identified through a handsearch of leading journals and a MEDLINE search. The final 9 articles selected were determined by consensus based on scientific rigor, relevance to hospital medicine, and impact on practice. RESULTS: Key findings include the following: scheduled antipsychotics were inferior to a placebo for nonterminal delirium; a low-dose morphine was superior to a weak opioid for moderate cancer pain; methadone as a coanalgesic improved high-intensity cancer pain; many hospitalized patients on comfort care still receive antimicrobials; video decision aids improved the rates of advance care planning (ACP) and hospice use and decreased costs; standardized, PC-led intervention did not improve psychological outcomes in families of patients with a chronic critical illness; caregivers of patients surviving a prolonged critical illness experienced high and persistent rates of depression; people with non-normative sexuality or gender faced additional stressors with partner loss; and physician trainees experienced significant moral distress with futile treatments. CONCLUSIONS: Recent research provides important guidance for clinicians caring for hospitalized patients with serious illnesses, including symptom management, ACP, moral distress, and outcomes of critical illness.

Prevalence and treatment of menopausal symptoms among breast cancer survivors.

Women diagnosed with breast cancer often experience early menopause secondary to treatment effects, yet physicians may be reluctant to prescribe hormone replacement therapy (HRT) because of the potential increased risk of recurrence. To assess the burden of menopausal symptoms, HRT use, and alternative treatments in recent breast cancer survivors, a population-based, case-control study was conducted among breast cancer survivors and age-matched controls. Wisconsin women 18-69 years old with a new diagnosis of breast cancer 8-11 months prior to interview (n = 110) and control subjects randomly selected from population lists (n = 73) responded to a standardized telephone questionnaire that elicited information on menopausal symptoms, estrogen and alternative therapies (prescription medications, vitamins, herbal preparations, soy products, acupuncture, chiropractic) used to alleviate symptoms. We used multivariate logistic regression to obtain odds ratios and 95% confidence intervals (CI) for symptoms of menopause, use of estrogen, and use of alternative therapies. Breast cancer survivors were 5.3 (95% CI 2.7-10.2) times more likely to experience symptoms, 25 (95% CI 8.3-100) times less likely to use estrogen, and 7.4 (95% CI 2.5-21.9) times more likely to use alternatives than controls. Soy, vitamin E, and herbal remedies were the most common alternative therapies reported by participants; use was greater in cases compared to controls. Most soy users reported increasing soy products specifically to reduce the chances of a diagnosis of recurrent breast cancer. Among cases, tamoxifen users (n = 62) reported a higher prevalence of symptoms and a higher prevalence of alternative treatments. This is the first population-based survey of menopausal symptoms and treatments that compares breast cancer cases with disease-free controls. Cases are both more likely to experience menopausal symptoms and less likely to use HRT than controls. Instead, cases treat menopausal symptoms with vitamin E and soy products, even though the safety and efficacy of these therapies are unproven. The increased use of soy products in this population has not been previously documented.

To stent or not to stent: an evidence-based approach to palliative procedures at the end of life.

Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence to inform the decision, focusing on the specific question of whether the benefits of palliative biliary stents in patients with advanced cancer outweigh the risks. We then apply the evidence to the issue of how the primary and/or palliative care team and the interventionist communicate with patients and their families about the risks and benefits of palliative procedures. Review of the evidence found several prospective case series without control groups that measured patient-centered outcomes. Studies had high attrition rates, results for improvements in symptoms and quality of life were mixed, and rates of complications and short-term mortality were high. In conclusion, the limited evidence does not support that the benefits of palliative biliary stents in this population outweigh the risks. We propose that primary care teams consider and discuss the larger picture of the goals of care with patients and families when considering offering these procedures, as well as benefits and potential harms, and consider involving palliative care services early, before consultation with an interventionist.

Medical issues and hormone replacement therapy.

The debate surrounding postmenopausal hormone replacement therapy (HRT) has become more contentious in the past decade. The relationship between HRT and venous thrombotic events has been confirmed, although the absolute risk is small. Evidence of a relationship between breast cancer and HRT is stronger. Randomized controlled trials reveal an association with cardiovascular events in women with known heart disease, a possibly diminished overall quality of life due to HRT, and worsening of urinary incontinence. There is also some evidence associating HRT with ovarian cancer. However, longitudinal studies continue to demonstrate over the long term that HRT use is associated with fewer cardiovascular events and a reduced risk of developing dementia. Future studies may show that a lower daily dose of HRT can reduce the risks while still providing benefit.