Lessons from the Literature

2019; Volume 20, No 6, June

Lessons from the Literature

Under My Microscope

Dr. Tania Pastrana

IAHPC research advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Daniel Gainza-Miranda, Eva Maria Sanz-Peces, Alberto Alonso-Babarro, María Varela-Cerdeira, Concepción Prados-Sánchez, Guadalupe Vega-Aleman, Ricardo Rodriguez-Barrientos, and Elena Polentinos-Castro. Breaking Barriers: Prospective Study of a Cohort of Advanced Chronic Obstructive Pulmonary Disease Patients To Describe Their Survival and End-of-Life Palliative Care Requirements. Journal of Palliative Medicine, Volume 22, Number 3, 2019. DOI: 10.1089/jpm.2018.0363 [Full text]

Traditionally, palliative care has been linked to cancer. With conceptual and practical transitions that have occurred since, other conditions are being recognized as targets of palliative care. The World Health Organization estimates that 10% of persons needing palliative care have chronic lung disease and a considerable symptom burden associated with severe health-related suffering. The need for integrated palliative care exists; however, little is known about what happens with persons in the advanced stages of chronic obstructive pulmonary disease (COPD) who receive home care.

This month’s article was written by a team in Spain that followed up on 60 patients in Madrid with advanced COPD who were attended by a palliative home care team. This observational prospective cohort study shows a decreased number of hospitalizations; in its conclusion, the study showed that care by a multidisciplinary team favored the development of advance care planning, decreased hospitalizations, and enabled death at home or in palliative care units.

By the way, this article was named 2019 Paper of the Year by the European Association for Palliative Care. Congratulations!

Background and Aim: Consensus has been reached on the need to integrate palliative care in the follow-up examinations of chronic obstructive pulmonary disease (COPD) patients. We analyzed the survival from the initiation of follow-up by a palliative home care team (PHCT) and described the needs and end-of-life process. Setting and Design: This study was a prospective observational cohort study of advanced COPD patients referred to a PHCT. Sociodemographic variables, survival from the start date of follow-up using the Kaplan–Meier model, health resource consumption, perceived quality of life, main symptomatology, opioid use, and advanced care planning (ACP) were analyzed. Results: Sixty patients were included. The median survival was 8.3 months. Forty-two patients died at the end of the study (85% at home or in palliative care units). The most frequent cause of death was respiratory failure in 39 patients (93%), with 29 of these patients requiring sedation (69%). Dyspnea at rest, with an average of 5 (standard deviation [SD] 2) points, was the main symptom. Fifty-five patients (91%) required opioids for symptom control. The median score in the St. George's Respiratory Questionnaire was 72 (SD 13). The mean number of visits by the home team was 7 (SD 6.5). The mean number of admissions during the monitoring period was 1.5 (SD 0.15). Conclusions: The characteristics of the cohort appear suitable for a PHCT. The follow-up care provided by our multidisciplinary unit decreased the number of hospitalizations, favored the development of ACP, and enabled death at home or in palliative care units.

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Media Watch: The ICU

IAHPC defines palliative care as ‘the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end of life’ – a concept gaining increasing acceptance in the ICU. The three articles below are selected from Barry R. Ashpole’s weekly Media Watch column.

‘As I discuss DNR/DNI status with patients and family members, I often feel frustrated by how my words fail to capture the full experience of receiving cardiac resuscitation: the stripping of the patient’s clothes, the nonstop rib-crushing compressions, the assault of IVs and wires, and the pure visceral nature of the event.’
Caring for dying patients: Visual narratives from the intensive care unit

Annals of Internal Medicine | Online – 1 January 2019 – The author started this series of drawings from her desire to illustrate her experiences as a medical student in treating intensive care patients through art... [T]he author hopes these images facilitate more mindful ways to care for patients and their families as they face illness and death. Each drawing represents a composite of patients she has encountered, and she used donated cadavers from the New York University Anatomy Lab to help accurately depict the anatomy in her illustrations.

Full (illustrated) text

Review: The role of palliative care in the cardiac intensive care unit

Healthcare | Online – 19 February 2019 – In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients admitted to cardiac intensive care units. Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions... In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed... However, implementation of these recommendations in clinical practice is still inconsistent. The authors analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.

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Editorial: Focus on ethics and palliative care in the intensive care unit

Intensive Care Medicine | Online – 25 March 2019 – This editorial highlights papers on prognostic and palliative care (PC) strategies for critically ill patients and their families published in Intensive Care Medicine (ICM) and other journals in the last two years, including five original research papers, one systematic review, one pragmatic review, six “what’s new,” two “understanding the disease,” and one editorial. Several decades of research have led to numerous treatment and technological advances resulting in improved ICU survival, but interventions to improve patient- and family-centered care have not kept pace. Emerging literature suggests there is a renewed focus on comprehensive approaches to critical care grounded in partnerships between patients, families, and healthcare professionals. This builds on the recognition the highest quality critical care is provided simultaneously with, not independently from, PC for all critically ill patients to address symptoms, communication about goals-of-care, family support, shared decision-making and, in some cases, dying.

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Media Watch, published by Barry R. Ashpole, a Canadian communications consultant and educator, monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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