Literature Review

Successful use of propofol after failed palliative sedation in patients with refractory symptoms[Spain] Journal of Palliative Medicine; Eduardo Garcia Romo, Bernadette Pfang, Beatriz Valle Borrego, Marta Lobo Antuña, Antonio Noguera Tejedor, Silvia Rubio Gomez, Victoria Galindo Vazquez, Blanca Prieto Rios; July 2024Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.Publisher's Note: An interesting study on palliative sedation, although findings would need to be put into an American context.

Disparities in end-of-life care for minoritized racial and ethnic patients during terminal hospitalizations in New York StateJournal of the American Geriatrics Society; Miguel Cid, Main Lin Quan Vega, Zhixin Yang, Jean Guglielminotti, Guohua Li, May Hua; 7/24Racial and ethnic minorities often receive care at different hospitals than non-Hispanic white patients, but how hospital characteristics influence the occurrence of disparities at the end of life is unknown. ... During terminal hospitalizations, Black patients were less likely than non-Hispanic White patients to have documented end-of-life care. This disparity appears to be more pronounced in non-teaching hospitals than in teaching hospitals.

The unintended and anticompetitive consequences of laws to control health care costsJAMA Forum; by Lanhee J. Chen; 6/24An array of federal and state laws, and accompanying regulations, restrict the supply of health care, driving up costs and making health care less affordable and accessible for many in the US. Too few health policy analysts and commentators have paid attention to these supply-side limitations that play a significant role in limiting the number of clinicians and health care facilities. Even though some of these policies were well-intentioned and designed to control costs, they have, in practice, undermined competition and ironically led to higher prices in the long run... Together, CON and COPA laws, as well as the ACA restrictions on POHs, have been associated with a host of unintended consequences, such as the aggregation of market power in increasingly larger health care facilities, limited access to care, and higher costs for patients. Indeed, these supply-side restrictions have been critiqued by analysts across the ideological spectrum. Policymakers at both the state and federal level should take note of the unintended effects of these laws and their accompanying regulatory provisions and consider whether their repeal or modification would benefit patients and the communities where they live.

Prognoses associated with Palliative Performance Scale scores in modern palliative care practiceJAMA Network Open; by Kara E Bischoff, Kanan Patel, W John Boscardin, David L O'Riordan, Steven Z Pantilat, Alexander K Smith; 7/1/24The Palliative Performance Scale (PPS) is one of the most widely used prognostic tools for patients with serious illness. However, current prognostic estimates associated with PPS scores are based on data that are over a decade old. ... Conclusions and relevance: In this prognostic study, prognostic estimates associated with PPS scores were substantially longer than previous estimates commonly used by clinicians. Based on these findings, an online calculator was updated to assist clinicians in reaching prognostic estimates that are more consistent with modern palliative care practice and specific to the patient's setting and diagnosis group.

Supporting the grieving child and family: Clinical reportAmerican Academy of Pediatrics; by David J. Schonfeld, MD, FAAP; Thomas Demaria, PhD; Arwa Nasir, MBBS, MSc, MPH, FAAP; Sairam Kumar, MD, FAAP; Committee on Pyschosocial Aspects of Child and Family Health; Council on Children and Disasters; 6/17/24At some point in their childhood, the majority of children will experience the death of a close family member or friend. Approximately 1 in 20 children in the United States experiences the death of a parent by the age of 16. ... The death of someone close to a child often has a profound and lifelong effect on the child and results in a range of both short- and long-term reactions. ... This clinical report offers practical suggestions on how to talk with grieving children to help them better understand what has happened and its implications. An understanding of guilt, shame, and other common reactions as well as an appreciation of the role of secondary losses and the unique challenges facing children in communities characterized by chronic trauma and cumulative loss will help the [healthcare professional] to address factors that may impair children’s adjustment and to identify complicated mourning and situations when professional counseling is indicated. Advice on how to support children’s participation in funerals and other memorial services and to anticipate and address grief triggers and anniversary reactions is provided. ...Editor's Note: This significant article can be downloaded and shared with your organization's clinicians. For additional, ongoing resources, explore the National Alliance for Children's Grief. If your hospice provides specialized children's grief services, are they listed on the NACG's "Find a Support Center or Camp Near You" search engine? Click here to add or update your listing.

National health expenditure projections, 2023–32: Payer trends diverge as pandemic-related policies fade Health Affairs - Research Article - Costs & Spending; by Jacqueline A. Fiore, Andrew J. Madison, John A. Poisal, Gigi A. Cuckler, Sheila D. Smith, Andrea M. Sisko, Sean P. Keehan, Kathryn E. Rennie, and Alyssa C. Gross; 6/12/24 Health care spending growth is expected to outpace that of the gross domestic product (GDP) during the coming decade, resulting in a health share of GDP that reaches 19.7 percent by 2032 (up from 17.3 percent in 2022). National health expenditures are projected to have grown 7.5 percent in 2023, when the COVID-19 public health emergency ended. This reflects broad increases in the use of health care, which is associated with an estimated 93.1 percent of the population being insured that year. ... Amonth eh major payers, Medicare has the highest projected ten-year average spending growth rath, mainly because of enrollment into the program. [Click on the title's link to examine this article's content and tables.]

A scoping review of dementia interventions in home-based primary careJournal of the American Medical Directors Association; by Jeffrey D. Weiner BA, Bruce Leff MD, Christine S. Ritchie MD, MSPH; 6/24Home-based primary care (HBPC) provides interdisciplinary, longitudinal, comprehensive care at home to homebound older adults. The prevalence of dementia among HBPC recipients is approximately 50%... Despite high prevalence of dementia among homebound older adults receiving HBPC, there are a dearth of studies on HBPC-specific dementia interventions. Future studies should consider adapting and testing interventions found to be effective in other settings to HBPC.

Nursing Home Star Ratings and end-of-life care quality: Lessons learned from the Veterans Health AdministrationJournal of the American Medical Directors Association; by Joan Carpenter, Daniel Kinder, Dawn Smith, Mary Ersek, Melissa Wachterman, Joshua Thorpe, Donald R Sullivan, Jennifer Bailey, Scott Shreve, Ann Kutney-Lee; 6/24Our findings suggest that the current [VA nursing homes, known as Community Living Centers (CLCs)] star rating system is not sufficient to assess the quality of EOL care. [The VA's Bereaved Family Survey (BFS)] scores, or a comparative EOL quality of care measure, should be integrated into CLC quality rating systems.Publisher's Note: If the VA is integrating an EOL quality measure into their NF Star Rating, should Medicare?

Palliative care for patients with cancer: ASCO guideline updateJournal of Clinical Oncology; by Justin J Sanders, Sarah Temin, Arun Ghoshal, Erin R Alesi, Zipporah Vunoro Ali, Cynthia Chauhan, James F Cleary, Andrew S Epstein, Janice I Firn, Joshua A Jones, Mark R Litzow, Debra Lundquist, Mabel Alejandra Mardones, Ryan David Nipp, Michael W Rabow, William E Rosa, Camilla Zimmermann, Betty R Ferrell; 7/24Evidence-based recommendations address the integration of palliative care in oncology. Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer. For patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services complementing existing or emerging supportive care interventions... The Expert Panel suggests early palliative care involvement, especially for patients with uncontrolled symptoms and QOL concerns. Clinicians caring for patients with solid tumors on phase I cancer trials may also refer them to specialist palliative care. Additional information is available at www.asco.org/supportive-careguidelines. 

End-of-life care needs in cancer patients: a qualitative study of patient and family experiences BMC Palliative Care; by Mario López-Salas, Antonio Yanes-Roldán, Ana Fernández, Ainhoa Marín, Ana I Martínez, Ana Monroy, José M Navarro, Marta Pino, Raquel Gómez, Saray Rodríguez, Sergio Garrido, Sonia Cousillas, Tatiana Navas, Víctor Lapeña, Belén Fernández; 6/21/24  Results: Four major themes emerged from the interviews that explored the needs and concerns of patients with cancer at the end of life: (1) physical well-being (2) emotional well-being (3) social well-being and (4) needs relating to information and autonomous decision-making. The interviews also shed light on the specific needs of family members during this period, namely the difficulties of managing increased caregiver burden and maintaining a healthy work-life balance.

Patient experiences of specialty palliative care in the perioperative period for cancer surgery Journal of Pain and Symptom Management; by Laura M Holdsworth, Rachel Siden, Anna Sophia Lessios, Mae Verano, Elizabeth Rickerson, Bridget Fahy, Fabian M Johnston, Brittany Waterman, Rebecca Aslakson; 6/19/24 online ahead of print  Context: Though patients undergoing treatment for upper gastrointestinal (GI) cancers frequently experience a range of sequelae and disease recurrence, patients often do not receive specialty palliative care soon after diagnosis and it is unknown in what ways they may benefit.  Results: We found five themes that characterized patient experiences and perceptions of specialty palliative care. Patients typically had limited prior awareness of palliative care (theme 1), but during the study, came to understand it as a "talking" intervention (theme 2). Patients whose concerns aligned with palliative care described it as being impactful on their care (theme 3). However, most patients expressed a focus on cure from their cancer and less perceived relevance for integration of palliative care (theme 4). Integrating specialist palliative care practitioners with surgical teams made it difficult for some patients to identify how palliative care practitioners differed from other members of their care team (theme 5).

The two phases of hospice—Declining Phase and Terminal PhaseJournal of Palliative Medicine; by Roy Zagieboylo, MD; 6/24I propose that hospice care should be identified as Declining Phase or Terminal Phase hospice care. ... In the Declining Phase, patients will usually have a gradual deterioration in function requiring more and more care. ... As many patients progress and their bodies fail, they may enter the Terminal Phase of hospice care. This phase is identified by the patient and family and is that time when the quality of life is so poor, there is no goal to increase the number of days alive. ... If, upon referral to hospice, a doctor was routinely asked “Is this a Declining Phase or Terminal Phase referral?” it would encourage discussion, education, and possibly a better understanding of the full scope of hospice care. If the nomenclature became widespread, it would also help patients and families better understand, appreciate, and accept earlier hospice referrals.