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.
© 2017 Society of Hospital Medicine
Cautions
Patients with chronic kidney disease (CKD) were excluded due to concerns about the accumulation of morphine metabolites. Additionally, this study was open label, increasing the risk of bias.
Implications
Low-dose morphine should be considered over the use of WOs to achieve better and more rapid pain control in patients without CKD.
The Use of Methadone as a Coanalgesic May Improve Moderate Cancer Pain
Courtemanche F, Dao D, Gagné F, et al. Methadone as a coanalgesic for palliative care cancer patients. J Palliat Med. 2016;19(9):972-978.
Background
Methadone is effective at treating cancer pain and is often utilized when patients have neuropathic pain, fail to respond to traditional opioids, or have renal failure.9,10 However, its long half-life and many drug interactions make methadone challenging to use.
Findings
This cohort study looked at 153 inpatient or outpatient PC patients in Montreal who received methadone as a coanalgesic for cancer pain. The patients’ median morphine equivalent dose was 120 mg when initiating methadone. The median starting dose of methadone was 3 mg per day. Of patients, 49.3% had a significant response (≥30% pain reduction), with a median response time of 7 days, and 30.1% achieved a substantial response (≥50% pain reduction), with a median response time of 3 days. Patients with higher initial pain scores were more likely to respond to adjuvant methadone. Those who had not responded after a week of methadone were unlikely to respond despite dose escalations. Adverse effects included drowsiness (51.4%), confusion (27.4%), constipation (24.7%), nausea (19.9%), and myoclonia (16.4%).
Cautions
This was an observational study with retrospective data, leading to higher levels of missing data. A high rate of adverse side effects was reported (90.4%). Further study is needed to validate and reproduce the findings.
Implications
The use of adjuvant low-dose methadone may be considered in patients with moderate pain despite high-dose opioids. If a response is not seen within 7 days, then methadone use should be reconsidered.
ANTIBIOTIC STEWARDSHIP
Many Hospitalized Patients on Comfort Care Still Receive Antimicrobials
Merel SE, Meier CA, McKinney CM, Pottinger PS. Antimicrobial use in patients on a comfort care protocol: a retrospective cohort study. J Palliat Med. 2016;19(11):1210-1214.
Background
It is unknown how often patients who are hospitalized at the end of life continue to receive antimicrobials and what factors are associated with antimicrobial use.
Findings
This retrospective cohort study of 1881 hospitalized adults transitioned to a comfort care order (CCO) set at 2 academic medical centers found that 77% of these patients received antimicrobials during their hospital stay (62.4% at 24 hours prior to CCO). Of the 711 still alive at ≥24 hours after CCO, 111 (15.6%) were still on antimicrobials, with that proportion remaining stable for the remainder of hospitalization. In comparing those who did and did not receive antimicrobials after 24 hours of CCO, the presence of a documented infection was not significantly different after adjusting for age. Those with a cancer diagnosis (adjusted risk ratio [ARR] = 1.44: P = .04), a longer length of stay (≥7 days vs <7 days; ARR = 1.49; P = .05), and those discharged home (ARR 2.93; P < .001) or to a facility (ARR 3.63; P < .001) versus dying in the hospital were more likely to be on antimicrobials 24 hours after CCO. Compared with those on a medicine service, patients in the medical and surgical intensive care units (ICUs) were less likely to receive antimicrobials (medical ICU ARR = 0.32; P = .01; surgical ICU and/or neuro-ICU ARR = 0.32; P = .02). The most commonly administered antimicrobials were fluoroquinolones and vancomycin.
Cautions
Only 111 patients were still on antimicrobials at 24 hours, which limited analysis. Investigators relied on retrospective data for medication administration and diagnoses.
Implications
Further work is needed to understand and address the expectations of clinicians, patients, and families regarding the role of antimicrobials at the end of life.
COMMUNICATION AND DECISION MAKING
Video Decision Aids Improved Rates of Advance Care Planning and Hospice Use and Decreased Costs
Volandes, AE, Paasche-Orlow MK, Davis AD et al. Use of video decision aids to promote advance care planning in Hilo, Hawai‘i. J Gen Intern Med. 2016;31(9):1035-1040.
Background
Advance care planning (ACP) can be enhanced with the use of video decision aids, which may help address scalability and cost.11 The Hawaii Medical Service Association began an initiative to improve ACP rates, which included a financial incentive. Clinician training and patient access to ACP videos were implemented 1 year into this campaign, which was intended for patients with late-stage disease.
