Herbert H. Watzke

Use of Thromboprophylaxis in Palliative Care Patients: A Survey Among Experts in Palliative Care, Oncology, Intensive Care, and Anticoagulation

Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovskys index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovskys index of 20 and by 85% when Karnovskys index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

Gender differences in caregiver burden and its determinants in family members of terminally ill cancer patients

Female family caregivers consistently report higher levels of stress and burden compared to male caregivers. Explanations for the apparently higher psychological vulnerability of female caregivers are largely missing to date. This study assesses the correlates and determinants of caregiver burden in family caregivers of advanced cancer patients with a specific focus on gender differences.

Critically ill patients with cancer: chances and limitations of intensive care medicine—a narrative review

This narrative review deals with the challenge of defining adequate therapy goals and intensive care unit (ICU) admission criteria for critically ill patients with cancer. Several specific complications of critically ill patients with cancer require close collaborations of intensive care and cancer specialists. Intensivists require a basic understanding of the pathophysiology, diagnosis and therapy of common cancer-specific problems. Cancer specialists must be knowledgeable in preventing, detecting and treating imminent or manifest organ failures. In case of one or more organ dysfunctions, ICU admissions must be evaluated early. In order to properly define the therapy goals for critically ill patients with cancer, decision-makers must be aware of the short-term intensive care prognosis as well as the long-term oncological options and perspectives. Multidisciplinary teamwork is key when it comes down to decisions on ICU admission, planning of therapeutic aims, patient management in the ICU and tailored therapy limiting with smooth transition into a palliative care (PC) setting, whenever appropriate.

Predicting discharge of palliative care inpatients by measuring their heart rate variability

OBJECTIVES Home discharge after hospital admission to an inpatient palliative care unit (PCU) is a major challenge. Dysfunction of the autonomic nervous system is commonly observed in patients with advanced cancer in this setting. The aim of this prospective observational study was to determine whether the measurement of heart rate variability (HRV) by assessing parameters of the autonomic nervous system on a 24-h-ECG at the time of admission to the PCU was correlated with the likelihood of discharge. METHODS Sixty hospitalized patients with advanced cancer of distinct origin, admitted to a PCU, were enrolled consecutively. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were obtained. HRV was measured over one day (20-24 hours) using a portable five-point ECG. The aim of the study was to compare HRV measurements in patients who could be discharged and those who died. The association of these variables with home discharge or death at the PCU was calculated. RESULTS Discharge was achieved in 45% of patients while 55% of patients died. Median KPS and median PPS on admission were significantly higher in discharged patients than in those who died (P=0.001). Patients who were discharged tended to have a higher HRV, although the difference was not significant. CONCLUSIONS KPS and PPS were significant predictors of the likelihood of discharge while HRV did not predict discharge.

Systemic activation of coagulation and fibrinolysis during varicose vein stripping

BACKGROUND Elevation of activation markers of blood coagulation (thrombin‐antithrombin complex [TAT], prothrombin fragment 1 + 2 [F1 + 2], D‐Dimer] has not only been found in clinically avert thrombosis but also reflects a prethrombotic state. OBJECTIVE The purpose of our study was to evaluate whether varicose vein stripping, an operative procedure with an extremely low risk of postoperative thromboembolism, induces a prethrombotic state by activation of the hemostatic system. METHODS In a prospective, observational study we compared the baseline and postoperative values of TAT, Fl + 2, and D‐Dimers in 15 patients undergoing varicose vein stripping and in 11 control patients undergoing surgical procedures associated with only minor soft tissue trauma. RESULTS A highly significant postoperative elevation of TAT (P < 0.001), Fl + 2 (P = 0.006), and D‐Dimer (P < 0.001) was observed in the varicose vein stripping group. No significant postoperative change of the respective parameters was detected in the control group. CONCLUSION We therefore conclude that varicose vein stripping induces a significant hemostatic system activation although postoperative thrombotic events are rare.

Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria

BackgroundThere is limited data on the use of thromboprophylaxis in patients with advanced cancer. We therefore aimed to study the practice of thromboprophylaxis in palliative care units in Austria.MethodsWe monitored use, indication, and contraindications to thromboprophylaxis in 134 patients hospitalized in 21 palliative care units in a prospective, cross-sectional study.ResultsForty-seven percent of patients were on low molecular weight heparin on the day of the study for primary or secondary thromboembolism. Thromboprophylaxis had been withdrawn in 18% of the patients upon admission to the palliative care unit. Contraindications for thromboprophylaxis were present in 27% of all patients. Cancer was present in 86% of the patients. The use of thromboprophylaxis was similar in cancer patients and in non-cancer patients (49% vs. 42%). Contraindications for thromboprophylaxis were present in 24% of all cancer patients. Significantly more bedridden cancer patients had contraindications for prophylaxis when compared with mobile cancer patients (35% vs. 16%; p = 0.03). Low performance status was by far the most frequent contraindication among these patients (89%). Seventy-one percent of all bedridden cancer patients were treated in accordance with common guidelines for thromboprophylaxis when contraindications were taken into account. Eighty-seven percent of patients who had been involved in decision making opted for getting prophylaxis.ConclusionsOur data reveal that about half of all cancer patients in palliative care units are treated with thromboprophylaxis. Low performance status was the most frequent contraindication for thromboprophylaxis.

What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient’s Expectations and Needs when Being Admitted to a Palliative Care Unit

Objective The aims of the study were to examine a) patients’ knowledge of palliative care, b) patients’ expectations and needs when being admitted to a palliative care unit, and c) patient’s concept of a good palliative care physician. Methods The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques. Results The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient’s language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment. Conclusions The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient’s needs will enable medical teams to improve professional and individualized care.

Decanucleotide insertion polymorphism of F7 significantly influences the risk of thrombosis in patients with essential thrombocythemia

There is strong evidence that certain thrombophilic single nucleotide polymorphisms (SNPs) account for an increased risk of thrombosis. The additive impact of inherited thrombotic risk factors to a certain disease‐ immanent thrombotic risk is vastly unknown. Therefore, we aimed to investigate the influence of three novel, preselected SNPs on the risk of thrombosis in patients diagnosed with myeloproliferative neoplasm (MPN).

Psyche at the end of life: Psychiatric symptoms are prevalent in patients admitted to a palliative care unit

OBJECTIVE Our aim was to evaluate the frequency and treatment of psychiatric symptoms in patients at palliative care units (PCUs). METHOD Patients admitted to one of five participating PCUs in Austria were included. The short version of the Patient Health Questionnaire (PHQ-D) was used to evaluate their mental health status. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 by patients and physicians. Patients with a previously diagnosed psychiatric disorder were compared to those without or with newly diagnosed psychiatric symptoms, based on PHQ-D results. Pain and psychopharmacological medication were assessed. Opioid doses were converted into oral morphine equivalents (OMEs). RESULTS Some 68 patients were included. Previously undetected psychiatric symptoms were identified in 38% (26 of 68), preexisting psychiatric comorbidities were evident in 25% (17), and no psychiatric symptoms were observed in 37% (25). Patients with a preexisting psychiatric comorbidity received antidepressants and benzodiazepines significantly more often than patients without or with previously undetected psychiatric symptoms (p < 0.001). Patient and physician median NRS ratings of pain intensity correlated significantly (p = 0.001). Median NRS rating showed no significant difference between patients with preexisting, previously undetected, or without psychiatric symptoms. OMEs did not differ significantly between preexisting, without, or previously undetected psychiatric symptoms. Patients with undetected and preexisting psychiatric comorbidities had a greater impairment in their activities of daily living than patients without psychiatric symptoms (p = 0.003). SIGNIFICANCE OF RESULTS Undetected psychiatric comorbidities are common in patients receiving palliative care. Screening for psychiatric symptoms should be integrated into standard palliative care to optimize treatment and reduce the psychosocial burden of the disease.

Decreased body mass index is associated with impaired survival in lung cancer patients with brain metastases: A retrospective analysis of 624 patients

&NA; Body mass index (BMI) is a prognostic factor in several cancer types. We investigated the prognostic role of BMI in a large patient cohort with newly diagnosed lung cancer brain metastases (BM) between 1990 and 2013. BMI at diagnosis of BM and graded prognostic assessment (GPA) were calculated. Definitions were underweight (BMI <18.50), weight within normal range (BMI 18.50‐24.99) and overweight (BMI ≥ 25.00). A total of 624 patients (men 401/624 [64.3%]; women 223/624 [35.7%]; median age of 61 [range 33‐88]) were analysed. Histology was non‐small cell lung cancer in 417/622 (66.8%), small cell lung cancer (SCLC) in 205/624 (32.9%) and not otherwise specified in 2/624 (0.3%) patients. About 313/624 (50.2%) had normal BMI, 272/624 (43.5%) were overweight and 39/624 (6.3%) were underweight. Underweight patients had shorter median overall survival (3 months) compared to patients with normal BMI (7 months) and overweight (8 months; p < .001; log rank test). At multivariate analysis, higher GPA class (HR 1.430; 95% cumulative incidence, CI 1.279‐1.598; p < .001; Cox regression model), SCLC histology (HR 1.310; 95% CI 1.101‐1.558) and presence of underweight (HR 1.845; 95% CI 1.317‐2.585; p = .014; Cox regression model) were independent prognostic factors. Underweight at diagnosis of BM in lung cancer is associated with an unfavourable prognosis.