Responses to assisted suicide requests

An interview study with Swiss palliative care physicians | BMJ Supportive & Palliative Care

Objectives: Assisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians’ involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.

 

Conclusions: The Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner’s values, but may not correspond to patients’ expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.

Full reference: Gamondi, C. et al.  (2017) Responses to assisted suicide requests: an interview study with Swiss palliative care physicians. BMJ Supportive & Palliative Care. Published Online: 11 August 2017.

Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life

Little is known about the patterns and predictors of the use of end-of-life health care among patients with acute myeloid leukemia (AML) | Journal of Clinical Oncology

End-of-life care is particularly relevant for older adults with AML because of their poor prognosis.

We performed a population-based, retrospective cohort study of patients with AML who were ≥ 66 years of age at diagnosis and diagnosed during the period from 1999 to 2011 and died before December 31, 2012. Medicare claims were used to assess patterns of hospice care and use of aggressive treatment. Predictors of these end points were evaluated using multivariable logistic regression analyses.

In the overall cohort (N = 13,156), hospice care after AML diagnosis increased from 31.3% in 1999 to 56.4% in 2012, but the increase was primarily driven by late hospice enrollment that occurred in the last 7 days of life. Among the 5,847 patients who enrolled in hospice, 47.4% and 28.8% started their first hospice enrollment in the last 7 and 3 days of life, respectively. Among patients who transferred in and out of hospice care, 62% received transfusions outside hospice. Additionally, the use of chemotherapy within the last 14 days of life increased from 7.7% in 1999 to 18.8% in 2012. Patients who were male and nonwhite were less likely to enroll in hospice and more likely to receive chemotherapy or be admitted to intensive care units at the end of life. Conversely, older patients were less likely to receive chemotherapy or have intensive care unit admission at the end of life, and were more likely to enroll in hospice.

End-of-life care for older patients with AML is suboptimal. Additional research is warranted to identify reasons for their low use of hospice services and strategies to enhance end-of-life care for these patients.

Full reference: Wang, R. et al. (2017) Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life. Journal of Clinical Oncology. Published online: 7th August 2017

Talking about end-of-life care

The purpose of the paper is to describe how residents express preferences for end-of-life (EOL) care | Geriatric Nursing

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For this qualitative study, we conducted semi-structured interviews and completed conventional content analysis to describe how residents’ expressed their preferences for care at the end of life. Sixteen residents from four nursing homes (NH) in southeastern Pennsylvania participated in this study. Residents were on average 88 years old, primarily non White, and widowed. Three key domains emerged from the analyses: Preferences for Today, Anticipating the End of My Life, and Preferences for Final Days. Residents linked their everyday living and EOL preferences by using ‘if and then’ logic to convey anticipation and readiness related to EOL. These findings suggest new strategies to start discussions of EOL care preferences with NH residents.

Full reference: Towsley, G.L. et al. (2017) Talking about end-of-life care: Perspectives of nursing home residents. Geriatric Nursing. Published online: 01 August 2017

Heart failure patients’ desires for spiritual care

Little information is available about HF patients’ desires regarding having their healthcare providers address their spiritual concerns, feeling constrained in doing so, and the extent to which their spiritual needs go unmet | Psychology, Health & Medicine

Nearly half of our sample reported high levels of unmet spiritual needs and reported moderately strong desires to have their doctor or other healthcare professional attend to their spiritual needs, and moderately strong feelings of constraint in doing so. Spiritual constraint and unmet spiritual needs were associated with poorer spiritual, psychological and physical well-being, but these effects varied, depending on patients’ desire to discuss spiritual needs. These findings have important implications for clinical management of HF patients.

Full reference: Park, C.L. & Sacco, S.J. (2017)Heart failure patients’ desires for spiritual care, perceived constraints, and unmet spiritual needs: relations with well-being and health-related quality of life. Psychology, Health & Medicine. Vol. 22 (no.9) pp. 1011-1020

Meditation Program and Healthcare Providers’ Interoceptive Awareness, Compassion Fatigue, and Burnout

Research suggests that meditation can relieve stress, cultivate self-regulation skills, improve ability to focus, and modify risk for compassion fatigue (CF) and burnout in healthcare providers | Journal of Hospice & Palliative Nursing

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This pilot study examined a novel 6-week technology-assisted meditation program, coherently grounded in the system of yoga therapy that required minimal time. Five 10- to 12-minute meditations were offered via smartphone apps supported by biweekly e-mails. Hospice and palliative professionals at a Midwestern US healthcare network participated in the program (n = 36). Each meditation integrated attention, synchronized breath, gentle movements and a meditation focus. Weekly e-mails introduced a new meditation and reminded participants how and why to practice.

The participants used the meditations a mean of 17.18(SD, 8.69) times. Paired t tests found significant presurvey to postsurvey improvements for CF/burnout and interoceptive awareness. Participation significantly heightened perceived ability and propensity to direct attention to bodily sensations, increased awareness of physical sensations’ connections to emotions, and increased active body listening. The technology-assisted yoga therapy meditation program successfully motivated providers to meditate. The program required minimal time yet seemed to reduce CF/burnout and improve emotional awareness and self-regulation by heightening attention to present-moment bodily sensations.

Full reference: Heeter, C. et al. (2017) Effects of a Technology-Assisted Meditation Program on Healthcare Providers’ Interoceptive Awareness, Compassion Fatigue, and Burnout.Journal of Hospice & Palliative Nursing. Volume 19 (Issue 4) pp. 314–322

Death talk and relief of death-related distress in patients with advanced cancer

An E, Wennberg E, Nissim R, et al. Death talk and relief of death-related distress in patients with advanced cancer.  BMJ Supportive & Palliative Care Published Online First: 02 August 2017. doi: 10.1136/bmjspcare-2016-001277

Objectives The circumstances of advanced cancer heighten the need for affected individuals to communicate mortality-related concerns, although there may be obstacles to such communication. Managing Cancer and Living Meaningfully(CALM) is a supportive-expressive therapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients and caregivers facing advanced disease. This study explores death-related distress in patients with advanced cancer and the perceived influence of CALM therapy on overcoming barriers to communication of this distress.

Methods Semistructured interviews were conducted with a subset of patients with advanced cancer (n=17) participating in a CALM phase III trial at a large urban regional cancer centre. Interviews were transcribed, and qualitative data were analysed using thematic analysis.

Results Death-related distress was experienced in terms of three key themes: diffuse and overwhelming fear, fear of uncertainty and fear of suffering. The perceived barriers to communicating such distress were as follows: reluctance of loved ones to discuss mortality-related issues and the participants’ own reluctance to discuss death-related concerns to protect their loved ones or themselves from distress. CALM therapists were perceived to facilitate discussions on dying and death in sessions and to support patients’ communication of death-related distress with healthcare providers and loved ones.

Conclusions Patients with advanced cancer perceive barriers to effective communication of death distress to be related to their own reluctance, as well as reluctance of their loved ones to address such fears. CALM therapy may help patients with advanced cancer to overcome obstacles to communication and to alleviate death-related distress.

A concept map of death-related anxieties in patients with advanced cancer

Vehling S, Malfitano C, Shnall J, et al. A concept map of death-related anxieties in patients with advanced cancer. BMJ Supportive & Palliative Care Published Online First: 02 August 2017. doi: 10.1136/bmjspcare-2016-001287

Objectives Fear of death and dying is common in patients with advanced cancer, but can be difficult to address in clinical conversations. We aimed to show that the experience of death anxiety may be deconstructed into a network of specific concerns and to provide a map of their interconnections to aid clinical exploration.

Methods We studied a sample of 382 patients with advanced cancer recruited from outpatient clinics at the Princess Margaret Cancer Centre, Toronto, Canada. Patients completed the 15-item Death and Dying Distress Scale (DADDS). We used item  ratings to estimate a regularised partial correlation network of death and dying-related concerns. We calculated node closeness-centrality, clustering and global network characteristics.

Results Death-related anxieties were highly frequent, each associated with at least moderate distress in 22%–55% of patients. Distress about ‘Running out of time’ was a central concern in the network. The network was organised into two areas: one about more practical fears concerning the process of dying and another about more psychosocial or existential concerns including relational problems, uncertainty about the future and missed opportunities. Both areas were yet closely connected by bridges which, for example, linked fear of suffering and a prolonged death to fear of burdening others.

Conclusions Patients with advanced cancer may have many interconnected death-related fears that can be patterned in individual ways. The bridging links between more practical and more psychosocial concerns emphasise that the alleviation of death anxiety may require interventions that integrate symptom management, advance care planning and psychological treatment approaches.