Gregory B. Crawford

Unmet needs of people with end-stage chronic obstructive pulmonary disease: recommendations for change in Australia

Chronic obstructive pulmonary disease (COPD) is an increasing cause of mortality. However, people with COPD are unlikely to receive care that meets the needs of themselves or their carers at the end of life.

Identifying palliative care patients with symptoms of depression: an algorithm

Introduction: Even though depression has serious and wide-ranging effects on outcomes in palliative care, errors in the identification of depressed patients are common. Objectives: To examine the clinical validity of widely publicised one-and two-question screening tools for depression in two palliative care settings. Also, to examine the construct validity and acceptability of a new empirically derived algorithm. Method: Participants were Australian palliative care patients in an inpatient hospice (n–22) or the community (n –69). Patients completed an unstructured interview about their feelings, questions relevant to three reference standards, two screening questions for depression and questions about the acceptability of the screening questions. Results: The clinical validity of the one-and two-question screening tools did not generalise across the two care settings. In contrast, the algorithm met stringent criteria for clinical validity for two reference standards in both settings. The algorithm also selectively identified patients whose unstructured interviews referred to themes consistent with depression. The algorithm includes potentially sensitive questions about anhedonia and depressed affect. However, almost all patients and staff reported that asking such questions soon after referral was acceptable. Conclusions:A four-question algorithm designed to identify patients who warrant follow-up for depression showed clinical validity, generalizability and construct validity, and the content was acceptable to patients and clinicians.

Pharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Delirium

INTRODUCTION Prescribing practice in hospice/palliative care is largely extrapolated from other areas of clinical practice, with few studies of net medication effects (benefits and harms) in hospice/palliative care to guide prescribing decisions. Hospice/palliative care patients differ in multiple ways from better studied participant groups, hence the applicability of studies in other participant groups is uncertain. Haloperidol, a butyrophenone derivative and dopamine antagonist, is commonly prescribed for nausea, vomiting, and delirium in hospice/palliative care. Its frequent use in delirium occurs despite little evidence of the effect of antipsychotics on the untreated course of delirium. The aim of this study was to examine the immediate and short-term clinical benefits and harms of haloperidol for delirium in hospice/palliative care patients. METHOD A consecutive cohort of participants from 14 centers across four countries who had haloperidol commenced for delirium were recruited. Data were collected at three time points: baseline, 48 hours (clinical benefits), and day 10 (clinical harms). Investigators were also able to report clinical harms at any time up to 14 days after it was commenced. RESULTS Of the 119 participants included, the average dose was 2.1 mg per 24 hours; 42 of 106 (35.2%) reported benefit at 48 hours. Harm was reported in 14 of 119 (12%) at 10 days, the most frequent being somnolence (n=11) and urinary retention (n=6). Seven participants had their medication ceased due to harms (2 for somnolence and 2 for rigidity). Approximately half (55/119) were still being treated with haloperidol after 10 days. CONCLUSION Overall, 1 in 3 participants gained net clinical benefit at 10 days.

PALLIATIVE CARE ON KANGAROO ISLAND

Kangaroo Island is the third largest island of Australia and the largest island off the coast of South Australia. A cross-sectional survey was conducted of professional carers and closest caring person of 15 patients who had died of malignant disease between 1994 and 1996. There was a high level of satisfaction with services provided on Kangaroo Island. There was regret about over-optimistic prognoses being given by specialist medical practitioners and considerable dissatisfaction with the service provided by tertiary hospitals. A divergence in assessment of symptoms was revealed between carers and professionals. There is need for improved training opportunities for community nurses, improved financial support for families dealing with malignancy and a need for more formalized bereavement services.

The geriatric depression scale in palliative care.

OBJECTIVE This research examined the psychometric properties of previously published short forms of the Geriatric Depression Scale (GDS) in patients receiving palliative care. It also uses the full form of the GDS to examine the prevalence of nonsomatic symptoms of depression in palliative patients. METHOD Participants were 84 patients with advanced cancer attending palliative care outpatient clinics. Scores for short forms of the GDS were derived from administering the original 30-item scale. Patients also completed the single item numerical analogue scale for depression from the Edmonton Symptom Assessment System and parallel numerical analogue scales for will-to-live and hope. A subset of the sample completed the measures twice. Short forms were judged on the extent to which they captured information gained from the full scale and their internal consistency, test-retest reliability, convergent and concurrent validity, and their distribution of scores. RESULTS Overall, five short forms showed good psychometric properties at both visits. Two of these forms were very brief. Some nonsomatic symptoms assessed on the full GDS were reported with high frequency. However, few individuals reported a large number of symptoms. At both visits, patients identified as likely to have severe depression gave different responses from other patients on most items on the GDS-30. SIGNIFICANCE OF RESULTS Several short forms of the GDS may be appropriate for use in palliative care. Patients identified as likely to have severe depression showed many of the same symptoms that characterise depression in other geriatric populations.

Furry and feathered family members--a critical review of their role in palliative care.

This article presents a comprehensive critical review of the peer-reviewed literature on palliative care and companion animals (CAs), reporting on the evidence and knowledge base regarding CAs and their role for people at end of life. PubMed, PsycINFO, Medline, Scopus, and Google Scholar were searched for studies pertaining to CAs, end of life, and hospice palliative care. Six studies dealt specifically with empirical research. The remaining literature addressed the topic peripherally or anecdotally. The evidence for efficacy and the knowledge base about the role of CAs at end of life in hospice and palliative care is weak. Further efforts are required to study the conditions under which CAs may be beneficial for patient care, including acceptability to staff, family, and other patients, and with consideration of welfare for the animals involved.

Left behind: cancer disparities in the developed world

Huge advances have been made in cancer treatments over recent decades; however, significant disparities still exist in the developed world on the basis of race, socioeconomic status, education level, geographical location, and immigration status and in the United States, insurance status. Cancer disparities persist in the continuum of cancer care from risk factors, screening, diagnosis, treatment, survivorship, and end-of-life care. The causes of disparities are complex and multifactorial. The MASCC (Multinational Association of Supportive Care in Cancer) Education Study Group would like to propose a framework of cancer disparities from a social perspective utilizing “social determinants of health” as delineated by the World Health Organization and highlight an unmet need for research and policy innovations to address cancer disparities in developed world.

Junior doctors' views of how their undergraduate clinical electives in palliative care influenced their current practice of medicine.

Purpose To explore how junior doctors (doctors in postgraduate training) retrospectively perceived the influence of their undergraduate palliative care attachments (clinical electives) on their current medical practice. Method From 2008 to 2013, 100 students participated in palliative care attachments at the University of Adelaide School of Medicine. In 2013, the authors invited 14 of these, now junior doctors, to be in this study. Participants took part in one-on-one, semistructured interviews. Interview data were analyzed for themes. Results Nine junior doctors participated. They were sent a summary of the findings to check whether the themes captured each participant’s experiences. Eight replied and agreed. Two main themes were identified: (1) from apprehension to gaining a sense of control, and (2) gaining perspective on the practice of medicine. Participants perceived that the learning experiences from the attachments provided them with a sense of confidence and control over their interactions with dying patients and families. This positive influence not only was present when caring for patients at the end of life but also influenced the participants’ identity as medical practitioners. Conclusions Findings suggest that junior doctors trained earlier in palliative care have enhanced competencies of professionalism, patient-centered medicine, psychosocial and spiritual aspects of palliative care, communication, teamwork, and self-awareness. Learning a palliative approach can help them make a difference in treating dying patients, but also in general patient care. Therefore, physicians trained in palliative care may be better prepared to contribute to a health care system that is person-centered, ethically conscientious, and personally fulfilling.

How Do Palliative Medicine Specialists Conceptualize Depression? Findings from a Qualitative In-Depth Interview Study

BACKGROUND AND OBJECTIVE Different professional conceptualizations of depression may complicate the clinical approach to depression in the palliative care setting. This study aimed to explore and characterize how palliative medicine specialists conceptualize depression. METHODS Palliative medicine specialists (i.e., consultants/attending physicians in palliative medicine) practicing in Australia were recruited. Participants were purposively sampled. Individual semi-structured, in-depth interviews were conducted to explore their conceptualizations of depression. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes. RESULTS Four main themes were identified in relation to the conceptualization of depression: (1) depression is a varied concept--it was variously considered as abnormal, a medical problem, an emotional experience, a social product, and an action-oriented construct; (2) depression has unclear boundaries, with differentiation between depression and sadness being especially challenging; (3) depression is different in the palliative care setting--it was seen as more understandable, and distinct from depression that predates life-limiting illnesses; and (4) depression is a challenging issue. CONCLUSIONS Depression is conceptualized by palliative medicine specialists in divergent, ontologically heterogeneous and ill-defined ways. A unitary concept of depression was not evident in this study. The concepts of depression need to be actively debated and refined in clinical practice, medical education, and research in order for more sophisticated and consistent models to be developed. The distinction of de novo depression from recurrent or persistent forms of depression also warrants further study.

End-Stage Kidney Disease A Survey of Recent Research to Support a Palliative Approach

This survey examines the quantity, quality, and accessibility of recent research that contributes to the evidence-based implementation of a palliative approach to end-stage kidney disease (ESKD). An electronic search identified published articles (between September2009 and August 2011) relevant to adults with ESKD (n = 1628). Few articles (n = 136) referred to key themes in a palliative approach to care: life-limiting illness, holistic care, and unit of care. Most of the relevant empirical articles used designs that did not allow a causal variable to be identified, and evaluations of interventions were rare. The literature was dispersed and often in journals unlikely to be regularly accessed by renal clinicians. Literature supporting the implementation of a full evidence-based palliative approach to ESKD is expanding but remains limited and is difficult to identify and access.