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Nursing home residents have poor outcomes after lower-extremity revascularization
A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.
In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.
“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.
Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.
Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.
The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.
The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.
One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).
The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”
They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.
The authors reported having no relevant financial disclosures.
The findings of Oresanya et al. are balanced and valuable, even though the data didn’t give them specific clinical information such as the indications for revascularization and were insensitive to subtle issues such as patient and family wishes for level of care. Such studies point the way to a more rational clinical approach to the care of frail elders with a limited life span but with the prospect of constant pain and discomfort.
But it is important to note that most of the procedures in this study likely were performed to relieve symptoms of ischemic leg pain, nonhealing wounds, or worsening gangrene. In this setting, the surgery should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend ambulatory function.
William J. Hall, M.D., is at the University of Rochester, New York. He reported having no relevant financial disclosures. Dr. Hall made these remarks in an invited commentary accompanying Dr. Oresanya’s report (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.32]).
The findings of Oresanya et al. are balanced and valuable, even though the data didn’t give them specific clinical information such as the indications for revascularization and were insensitive to subtle issues such as patient and family wishes for level of care. Such studies point the way to a more rational clinical approach to the care of frail elders with a limited life span but with the prospect of constant pain and discomfort.
But it is important to note that most of the procedures in this study likely were performed to relieve symptoms of ischemic leg pain, nonhealing wounds, or worsening gangrene. In this setting, the surgery should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend ambulatory function.
William J. Hall, M.D., is at the University of Rochester, New York. He reported having no relevant financial disclosures. Dr. Hall made these remarks in an invited commentary accompanying Dr. Oresanya’s report (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.32]).
The findings of Oresanya et al. are balanced and valuable, even though the data didn’t give them specific clinical information such as the indications for revascularization and were insensitive to subtle issues such as patient and family wishes for level of care. Such studies point the way to a more rational clinical approach to the care of frail elders with a limited life span but with the prospect of constant pain and discomfort.
But it is important to note that most of the procedures in this study likely were performed to relieve symptoms of ischemic leg pain, nonhealing wounds, or worsening gangrene. In this setting, the surgery should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend ambulatory function.
William J. Hall, M.D., is at the University of Rochester, New York. He reported having no relevant financial disclosures. Dr. Hall made these remarks in an invited commentary accompanying Dr. Oresanya’s report (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.32]).
A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.
In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.
“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.
Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.
Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.
The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.
The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.
One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).
The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”
They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.
The authors reported having no relevant financial disclosures.
A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.
In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.
“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.
Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.
Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.
The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.
The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.
One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).
The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”
They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.
The authors reported having no relevant financial disclosures.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Many nursing home residents undergo lower-extremity revascularization every year, but few survive and are ambulatory 1 year later.
Major finding: One year after lower-extremity revascularization, mortality was approximately 50%, only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status.
Data source: A population-based cohort study involving almost all (10,784) U.S. nursing home residents who had lower-extremity revascularization in 2005-2008 and were followed for 1 year.
Disclosures: This study was supported in part by the National Institute on Aging and the University of California, San Francisco, Claude D. Pepper Older Americans Independence Center. Dr. Oresanya and his associates reported having no relevant financial disclosures.
Palliative surgery eases pain at end of life
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
Key clinical point: Palliative surgery in patients with advanced cancers can relieve pain with minimal morbidity.
Major finding: Pain scores improved significantly from the pre- to postoperative periods, without a significant decline in performance status scores.
Data source: Case series of 202 patients with stage III or IV malignancies who underwent 247 palliative procedures.
Disclosures: The study was internally funded. Dr. Falor reported having no conflicts of interest.
HM15 Session Analysis: End-of-Life Discussions
Presenter: Julia Ragland, MD, FHM
Summation: Discussion of Prognosis in Advance Illness is a key component of informed decision-making and should be undertaken during a “Sentinel Hospitalization” and at times of other “triggers”. End-of-Life discussions are critical for providing the best care for patients with advanced diseases.
A Sentinel Hospitalization is a hospitalization in the patient’s disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care.
Other triggers for discussing prognosis: new diagnosis of serious illness, major medical decision with uncertain outcome, frequent hospitalizations for advanced disease, patient/family query prognosis, patient/family request treatment inconsistent with good clinical judgment (futile care), patient actively dying, “No” answer to “Surprise Question” (“would you be surprised if this patient died in the next year?”)
How can we prognosticate? Data from studies, Clinical intuition and experience, Prognostic indices, Key indicators of worsening prognosis (declining functional status, weight loss/malnutrition, co-morbidities, frequent hospitalizations)
Resources for Prognostication: ePrognosis, Seattle Heart Failure Model, MELD, Charlson Comorbidity Index, MJHSpalliativeinstitute.org/e-learning, Palliative Care Fast Facts mobile app
Ask-Tell-Ask method for communicating prognosis
- ASK: if they want to talk about prognosis and what they already know
- TELL: give information in small amounts, build on what they already know, use simple straight-forward language
- ASK: repeat understanding of what has been said, if they would like to hear more
Key Points/HM Takeaways:
- Estimating and discussing prognosis are core competencies for hospitalists and should be utilized during a “sentinel hospitalization”
- Prognostic awareness in advanced illness is key for:
- Informed decision making (CPR, procedures, chemo, et al)
- Determining realistic goals of care
- Providing patient centered care
- Most patients and families want prognostic information, but not always- must ask to know. Give the patient the option not to discuss prognosis.
- Ask-Tell-Ask approach for discussing prognosis is effective
Presenter: Julia Ragland, MD, FHM
Summation: Discussion of Prognosis in Advance Illness is a key component of informed decision-making and should be undertaken during a “Sentinel Hospitalization” and at times of other “triggers”. End-of-Life discussions are critical for providing the best care for patients with advanced diseases.
A Sentinel Hospitalization is a hospitalization in the patient’s disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care.
Other triggers for discussing prognosis: new diagnosis of serious illness, major medical decision with uncertain outcome, frequent hospitalizations for advanced disease, patient/family query prognosis, patient/family request treatment inconsistent with good clinical judgment (futile care), patient actively dying, “No” answer to “Surprise Question” (“would you be surprised if this patient died in the next year?”)
How can we prognosticate? Data from studies, Clinical intuition and experience, Prognostic indices, Key indicators of worsening prognosis (declining functional status, weight loss/malnutrition, co-morbidities, frequent hospitalizations)
Resources for Prognostication: ePrognosis, Seattle Heart Failure Model, MELD, Charlson Comorbidity Index, MJHSpalliativeinstitute.org/e-learning, Palliative Care Fast Facts mobile app
Ask-Tell-Ask method for communicating prognosis
- ASK: if they want to talk about prognosis and what they already know
- TELL: give information in small amounts, build on what they already know, use simple straight-forward language
- ASK: repeat understanding of what has been said, if they would like to hear more
Key Points/HM Takeaways:
- Estimating and discussing prognosis are core competencies for hospitalists and should be utilized during a “sentinel hospitalization”
- Prognostic awareness in advanced illness is key for:
- Informed decision making (CPR, procedures, chemo, et al)
- Determining realistic goals of care
- Providing patient centered care
- Most patients and families want prognostic information, but not always- must ask to know. Give the patient the option not to discuss prognosis.
- Ask-Tell-Ask approach for discussing prognosis is effective
Presenter: Julia Ragland, MD, FHM
Summation: Discussion of Prognosis in Advance Illness is a key component of informed decision-making and should be undertaken during a “Sentinel Hospitalization” and at times of other “triggers”. End-of-Life discussions are critical for providing the best care for patients with advanced diseases.
A Sentinel Hospitalization is a hospitalization in the patient’s disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care.
Other triggers for discussing prognosis: new diagnosis of serious illness, major medical decision with uncertain outcome, frequent hospitalizations for advanced disease, patient/family query prognosis, patient/family request treatment inconsistent with good clinical judgment (futile care), patient actively dying, “No” answer to “Surprise Question” (“would you be surprised if this patient died in the next year?”)
How can we prognosticate? Data from studies, Clinical intuition and experience, Prognostic indices, Key indicators of worsening prognosis (declining functional status, weight loss/malnutrition, co-morbidities, frequent hospitalizations)
Resources for Prognostication: ePrognosis, Seattle Heart Failure Model, MELD, Charlson Comorbidity Index, MJHSpalliativeinstitute.org/e-learning, Palliative Care Fast Facts mobile app
Ask-Tell-Ask method for communicating prognosis
- ASK: if they want to talk about prognosis and what they already know
- TELL: give information in small amounts, build on what they already know, use simple straight-forward language
- ASK: repeat understanding of what has been said, if they would like to hear more
Key Points/HM Takeaways:
- Estimating and discussing prognosis are core competencies for hospitalists and should be utilized during a “sentinel hospitalization”
- Prognostic awareness in advanced illness is key for:
- Informed decision making (CPR, procedures, chemo, et al)
- Determining realistic goals of care
- Providing patient centered care
- Most patients and families want prognostic information, but not always- must ask to know. Give the patient the option not to discuss prognosis.
- Ask-Tell-Ask approach for discussing prognosis is effective
Addressing pain at the end of life
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.
Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.
It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.
Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%. Among patients with a history of opioid abuse, the risk of addiction is still only 1%.
Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.
This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.
Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.
Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.
Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland. He is board certified in hospice and palliative medicine.
Is Neurosurgery Right for Your Patient?
Some patients who present with central nervous system metastasis should receive urgent neurosurgical consult, according to Corey D. Adamson, MD. This consult can help determine potential benefit and danger related to surgical resection of the brain.
“There is a subset of these patients where if we do a good job and pick the right patient, we can have a huge impact on survival,” Adamson said. “As a surgeon we are really looking at the neurologic problem and how we can fix that and maintain a good functional status.”
Some patients who present with central nervous system metastasis should receive urgent neurosurgical consult, according to Corey D. Adamson, MD. This consult can help determine potential benefit and danger related to surgical resection of the brain.
“There is a subset of these patients where if we do a good job and pick the right patient, we can have a huge impact on survival,” Adamson said. “As a surgeon we are really looking at the neurologic problem and how we can fix that and maintain a good functional status.”
Some patients who present with central nervous system metastasis should receive urgent neurosurgical consult, according to Corey D. Adamson, MD. This consult can help determine potential benefit and danger related to surgical resection of the brain.
“There is a subset of these patients where if we do a good job and pick the right patient, we can have a huge impact on survival,” Adamson said. “As a surgeon we are really looking at the neurologic problem and how we can fix that and maintain a good functional status.”
Appropriate Cancer Care in the Elderly
Physicians treating older patients with cancer should evaluate the patient’s physiologic, not chronologic, age when determining appropriate care, according to Lodovico Balducci, MD.
“Older age by itself is not a contraindication to the treatment of cancer,” Balducci said. “Age by itself is not a reason to reduce the dose of cancer treatment. Doctors may hurt their older patients, not because they treat them too much, but because they don’t treat them enough.”
Physicians treating older patients with cancer should evaluate the patient’s physiologic, not chronologic, age when determining appropriate care, according to Lodovico Balducci, MD.
“Older age by itself is not a contraindication to the treatment of cancer,” Balducci said. “Age by itself is not a reason to reduce the dose of cancer treatment. Doctors may hurt their older patients, not because they treat them too much, but because they don’t treat them enough.”
Physicians treating older patients with cancer should evaluate the patient’s physiologic, not chronologic, age when determining appropriate care, according to Lodovico Balducci, MD.
“Older age by itself is not a contraindication to the treatment of cancer,” Balducci said. “Age by itself is not a reason to reduce the dose of cancer treatment. Doctors may hurt their older patients, not because they treat them too much, but because they don’t treat them enough.”
California physicians sue state over suicide law
A group of physicians and patients are suing the state of California over a law that they say exposes doctors to criminal prosecution for providing terminally ill patients aid in dying.
Three doctors and three cancer patients – two of whom are also doctors – filed suit against the state Feb. 11, calling on California to clarify a portion of its assisted-suicide statute. The law makes it a felony to deliberately help a person commit suicide.
In their suit, the plaintiffs claim physicians who write prescriptions for mentally competent, terminally ill patients should not face legal penalties. The choice for a peaceful death by a dying patient is not suicide, nor is a physician assisting such a patient in “committing suicide,” the complaint argues. Additionally, the physicians assert that patients facing the end of their lives have a right under the California State Constitution to make autonomous decisions about their bodies and how they will die.
In a February statement, plaintiff Dr. Robert Brody, professor of medicine at the University of California, San Francisco, said competent, terminally ill adults have the right to a peaceful death in a controlled and clinically sound way.
“The current murky legal landscape means that physicians are placed at risk and must choose between potentially skirting the law to respect their patients’ choices or abandoning them to bad information, uncertainty, or violence,” he said in the statement.
The lawsuit comes after the high-profile death of terminally ill patient Brittany Maynard, who moved from California to Oregon to take advantage of that state’s Death with Dignity law.
The Disability Rights Legal Center, which is representing the plaintiffs in the California case, also recently filed suit in New York over the same issue. In that case, several physicians and patients are asking New York judges to clarify the ability of mentally competent, terminally ill New York patients to obtain aid in dying from their physician.
On Twitter @legal_med
A group of physicians and patients are suing the state of California over a law that they say exposes doctors to criminal prosecution for providing terminally ill patients aid in dying.
Three doctors and three cancer patients – two of whom are also doctors – filed suit against the state Feb. 11, calling on California to clarify a portion of its assisted-suicide statute. The law makes it a felony to deliberately help a person commit suicide.
In their suit, the plaintiffs claim physicians who write prescriptions for mentally competent, terminally ill patients should not face legal penalties. The choice for a peaceful death by a dying patient is not suicide, nor is a physician assisting such a patient in “committing suicide,” the complaint argues. Additionally, the physicians assert that patients facing the end of their lives have a right under the California State Constitution to make autonomous decisions about their bodies and how they will die.
In a February statement, plaintiff Dr. Robert Brody, professor of medicine at the University of California, San Francisco, said competent, terminally ill adults have the right to a peaceful death in a controlled and clinically sound way.
“The current murky legal landscape means that physicians are placed at risk and must choose between potentially skirting the law to respect their patients’ choices or abandoning them to bad information, uncertainty, or violence,” he said in the statement.
The lawsuit comes after the high-profile death of terminally ill patient Brittany Maynard, who moved from California to Oregon to take advantage of that state’s Death with Dignity law.
The Disability Rights Legal Center, which is representing the plaintiffs in the California case, also recently filed suit in New York over the same issue. In that case, several physicians and patients are asking New York judges to clarify the ability of mentally competent, terminally ill New York patients to obtain aid in dying from their physician.
On Twitter @legal_med
A group of physicians and patients are suing the state of California over a law that they say exposes doctors to criminal prosecution for providing terminally ill patients aid in dying.
Three doctors and three cancer patients – two of whom are also doctors – filed suit against the state Feb. 11, calling on California to clarify a portion of its assisted-suicide statute. The law makes it a felony to deliberately help a person commit suicide.
In their suit, the plaintiffs claim physicians who write prescriptions for mentally competent, terminally ill patients should not face legal penalties. The choice for a peaceful death by a dying patient is not suicide, nor is a physician assisting such a patient in “committing suicide,” the complaint argues. Additionally, the physicians assert that patients facing the end of their lives have a right under the California State Constitution to make autonomous decisions about their bodies and how they will die.
In a February statement, plaintiff Dr. Robert Brody, professor of medicine at the University of California, San Francisco, said competent, terminally ill adults have the right to a peaceful death in a controlled and clinically sound way.
“The current murky legal landscape means that physicians are placed at risk and must choose between potentially skirting the law to respect their patients’ choices or abandoning them to bad information, uncertainty, or violence,” he said in the statement.
The lawsuit comes after the high-profile death of terminally ill patient Brittany Maynard, who moved from California to Oregon to take advantage of that state’s Death with Dignity law.
The Disability Rights Legal Center, which is representing the plaintiffs in the California case, also recently filed suit in New York over the same issue. In that case, several physicians and patients are asking New York judges to clarify the ability of mentally competent, terminally ill New York patients to obtain aid in dying from their physician.
On Twitter @legal_med
Physical signs indicate impending death in cancer patients
Several physical symptoms may signal upcoming death in advanced cancer patients, said Dr. David Hui and his colleagues in the department of palliative care and rehabilitation medicine at the University of Texas MD Anderson Cancer Center, Houston.
In a study of 357 advanced cancer patients in palliative care, 203 of whom died, eight specific symptoms were associated with death within 3 days. These physical signs were nonreactive pupils (positive likelihood ratio [LR], = 16.7), decreased response to verbal stimuli (LR, 8.3), decreased response to visual stimuli (LR, 6.7), inability to close the eyelids (LR, 13.6), drooping of the nasolabial fold (LR, 8.3), hyperextension of the neck (LR, 7.3), grunting of vocal chords (LR, 11.8), and upper gastrointestinal bleeding (LR, 10.3), the authors reported.
“The use of these bedside physical signs individually or in combination may assist clinicians in making the diagnosis of impending death,” Dr. Hui and his associates wrote.
Read the full article in Cancer at doi:10.1002/cncr.29048.
Several physical symptoms may signal upcoming death in advanced cancer patients, said Dr. David Hui and his colleagues in the department of palliative care and rehabilitation medicine at the University of Texas MD Anderson Cancer Center, Houston.
In a study of 357 advanced cancer patients in palliative care, 203 of whom died, eight specific symptoms were associated with death within 3 days. These physical signs were nonreactive pupils (positive likelihood ratio [LR], = 16.7), decreased response to verbal stimuli (LR, 8.3), decreased response to visual stimuli (LR, 6.7), inability to close the eyelids (LR, 13.6), drooping of the nasolabial fold (LR, 8.3), hyperextension of the neck (LR, 7.3), grunting of vocal chords (LR, 11.8), and upper gastrointestinal bleeding (LR, 10.3), the authors reported.
“The use of these bedside physical signs individually or in combination may assist clinicians in making the diagnosis of impending death,” Dr. Hui and his associates wrote.
Read the full article in Cancer at doi:10.1002/cncr.29048.
Several physical symptoms may signal upcoming death in advanced cancer patients, said Dr. David Hui and his colleagues in the department of palliative care and rehabilitation medicine at the University of Texas MD Anderson Cancer Center, Houston.
In a study of 357 advanced cancer patients in palliative care, 203 of whom died, eight specific symptoms were associated with death within 3 days. These physical signs were nonreactive pupils (positive likelihood ratio [LR], = 16.7), decreased response to verbal stimuli (LR, 8.3), decreased response to visual stimuli (LR, 6.7), inability to close the eyelids (LR, 13.6), drooping of the nasolabial fold (LR, 8.3), hyperextension of the neck (LR, 7.3), grunting of vocal chords (LR, 11.8), and upper gastrointestinal bleeding (LR, 10.3), the authors reported.
“The use of these bedside physical signs individually or in combination may assist clinicians in making the diagnosis of impending death,” Dr. Hui and his associates wrote.
Read the full article in Cancer at doi:10.1002/cncr.29048.
How Alternative Medicine Can Help Your Patients
VA patients with cancer may benefit from adding complementary and alternative medicine (CAM), according to Chen Wang of the VA Ann Arbor Healthcare System in Michigan.
“Currently, no data exist on the use of CAM among veteran cancer patients,” Wang explained. “We surveyed patients over a 3-month period, using an anonymous, validated survey. Out of 129 veterans, only 29 were using CAM.”
VA patients with cancer may benefit from adding complementary and alternative medicine (CAM), according to Chen Wang of the VA Ann Arbor Healthcare System in Michigan.
“Currently, no data exist on the use of CAM among veteran cancer patients,” Wang explained. “We surveyed patients over a 3-month period, using an anonymous, validated survey. Out of 129 veterans, only 29 were using CAM.”
VA patients with cancer may benefit from adding complementary and alternative medicine (CAM), according to Chen Wang of the VA Ann Arbor Healthcare System in Michigan.
“Currently, no data exist on the use of CAM among veteran cancer patients,” Wang explained. “We surveyed patients over a 3-month period, using an anonymous, validated survey. Out of 129 veterans, only 29 were using CAM.”
Rise in reports of pain, depression in last year of life in oncology patients
The extent of pain, depression, and anorexia are rising in the last year of life for oncology patients, based on a survey of their family members.
Moderate or severe pain was experienced for at least a month by over 57% of 7,204 patients in their last year of life, and the incidence of pain appears to have increased between 1998 and 2010, based on data from participants who died during the longitudinal, community-based Health and Retirement study. Patients’ family members also reported that over 51% of patients experienced depression and 64% experienced anorexia in their last year of life.
The data reflect increases in the incidence of moderate to severe pain from nearly 47% in 1998-2000 to nearly 55% in 2008-2010. Increases also were noted in reports of depression and periodic confusion, researchers reported in the Feb. 2 online edition of Annals of Internal Medicine [doi:10.7326/M13-1609]). .
The researchers note other studies indicate that the intensity of treatment and the rate of adverse transitions have been increasing near the end of life. While hospice care is on the rise, it is often “tacked on” to this more intense late-life care; the median hospice stay is less than 3 weeks and such patients may not achieve symptomatic relief. Patients may not have consistent access to palliative services in outpatient, home, and long-term facility settings where most of the course of a terminal illness takes place, wrote Adam E. Singer of the Pardee RAND Graduate School, Santa Monica, Calif., and his colleagues.
The study was supported by the National Institute of Nursing Research and the Medical Scientist Training Program at the University of California.
The extent of pain, depression, and anorexia are rising in the last year of life for oncology patients, based on a survey of their family members.
Moderate or severe pain was experienced for at least a month by over 57% of 7,204 patients in their last year of life, and the incidence of pain appears to have increased between 1998 and 2010, based on data from participants who died during the longitudinal, community-based Health and Retirement study. Patients’ family members also reported that over 51% of patients experienced depression and 64% experienced anorexia in their last year of life.
The data reflect increases in the incidence of moderate to severe pain from nearly 47% in 1998-2000 to nearly 55% in 2008-2010. Increases also were noted in reports of depression and periodic confusion, researchers reported in the Feb. 2 online edition of Annals of Internal Medicine [doi:10.7326/M13-1609]). .
The researchers note other studies indicate that the intensity of treatment and the rate of adverse transitions have been increasing near the end of life. While hospice care is on the rise, it is often “tacked on” to this more intense late-life care; the median hospice stay is less than 3 weeks and such patients may not achieve symptomatic relief. Patients may not have consistent access to palliative services in outpatient, home, and long-term facility settings where most of the course of a terminal illness takes place, wrote Adam E. Singer of the Pardee RAND Graduate School, Santa Monica, Calif., and his colleagues.
The study was supported by the National Institute of Nursing Research and the Medical Scientist Training Program at the University of California.
The extent of pain, depression, and anorexia are rising in the last year of life for oncology patients, based on a survey of their family members.
Moderate or severe pain was experienced for at least a month by over 57% of 7,204 patients in their last year of life, and the incidence of pain appears to have increased between 1998 and 2010, based on data from participants who died during the longitudinal, community-based Health and Retirement study. Patients’ family members also reported that over 51% of patients experienced depression and 64% experienced anorexia in their last year of life.
The data reflect increases in the incidence of moderate to severe pain from nearly 47% in 1998-2000 to nearly 55% in 2008-2010. Increases also were noted in reports of depression and periodic confusion, researchers reported in the Feb. 2 online edition of Annals of Internal Medicine [doi:10.7326/M13-1609]). .
The researchers note other studies indicate that the intensity of treatment and the rate of adverse transitions have been increasing near the end of life. While hospice care is on the rise, it is often “tacked on” to this more intense late-life care; the median hospice stay is less than 3 weeks and such patients may not achieve symptomatic relief. Patients may not have consistent access to palliative services in outpatient, home, and long-term facility settings where most of the course of a terminal illness takes place, wrote Adam E. Singer of the Pardee RAND Graduate School, Santa Monica, Calif., and his colleagues.
The study was supported by the National Institute of Nursing Research and the Medical Scientist Training Program at the University of California.
FROM THE ANNALS OF INTERNAL MEDICINE
Key clinical point: Despite an increase in the use of hospice, moderate or severe pain continues to be a problem at the end of life for over half of patients.
Major finding: In their last year of life, over 57% of cancer patients experienced pain, 51% experienced depression, and 64% experienced anorexia.
Data source: Data from 7,204 deaths in the longitudinal, community-based Health and Retirement study.
Disclosures: The study was supported by the National Institute of Nursing Research (NINR) and the Medical Scientist Training Program at the University of California. Some of the researchers received grants from NINR.