Hunter Groninger

Chemotherapy-induced nausea and vomiting: an overview and comparison of three consensus guidelines

Chemotherapy-induced nausea and vomiting (CINV) remains one of the most debilitating toxicities associated with cancer treatment. In recent decades, significant strides have been made in our understanding of the pathophysiology of CINV, making way to more effective targeted pharmacotherapies, especially 5-hydroxytryptamine3 receptor antagonists and neurokinin-1 (NK-1) receptor antagonists. As much as 70%–80% of CINV can be prevented with appropriate administration of available antiemetics. Nevertheless, fear of CINV still may diminish cancer treatment adherence. To assimilate and summarise the rapidly growing body of clinical research literature on CINV, three professional organisations—the Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology, the American Society of Clinical Oncology and the National Comprehensive Cancer Network—have created CINV management guidelines. While these respective guidelines are developed from similar consensus processes using similar clinical research literature, their results demonstrate several key differences in recommended strategies. This article aims to provide an overview of CINV pathophysiology, compare and contrast three expert guidelines and offer considerations for future clinical and research challenges.

Choosing Words Wisely in Communication With Patients With Heart Failure and Families.

The complex and often unpredictable course of heart failure (HF) provides many opportunities for communication between clinicians and patients about important subjects as advance care planning, disease state education, therapeutic options and limitations, and end-of-life care. Studies of patients with HF demonstrate that, when engaging in such complex communication, specific language matters in patient experience and in shared decision-making with providers. To date, clinical reports have outlined useful frameworks for communication with patients with HF but have not yet broached specific language crucial to furthering whole person care, particularly in the complex and emotional realm of advancing disease and transitions to end-of-life care. In this work, the investigators unpack language commonly used in advanced HF care and provide explicit suggestions to better provide such pivotal communication. In conclusion, specific phrasing may significantly impact patient experiences and outcomes. Communication that focuses on the disease itself and the therapy or intervention in question may help remove the patient from potential negative emotions, thus facilitating more objective shared decision-making with the clinician.

Palliative care in cardiac transplantation: an evolving model

It is currently estimated that 5.7 million Americans live with heart failure. Of these, less than 3000 will receive a heart transplant this year, according to the US Department of Health and Human Services Organ Procurement and Transplantation Network. With successful transplantation can come significant emotional and physical symptoms that are not always addressed. Although palliative care is an interdisciplinary subspecialty designed to alleviate multiple domains of suffering in serious illness, many mistakenly associate it solely with the end of life. Traditionally associated with cancer, research into the role of palliative care in other chronic illnesses and complex life-changing therapies such as solid organ transplantation remains scarce but is nonetheless developing. Here, we try to investigate a potential role for palliative care for heart transplant recipients. Early research thus far has demonstrated importance of early involvement of palliative care teams and the significant improvement of physical and emotional symptoms in the pre- and post-transplant period. Nevertheless, more research is warranted to determine the ideal timing of palliative care integration, the effects on health care resource utilization, and whether improving quality of life can affect morbidity and mortality. By understanding these critical elements and others we may be able to develop a model for the role of palliative care for heart transplant patients.

Integrating Spiritual Care into Palliative Consultation: A Case Study in Expanded Practice

Recognizing and addressing spiritual needs has long been identified as a key component of palliative care (PC). More often than not, the provision of spiritual care involves referral to a hospital chaplain. In this study, we aim to describe the role of a PC chaplain embedded within the interdisciplinary PC team and demonstrate how this palliative chaplain role differs from that of a traditional hospital chaplain. We postulate that integrating spiritual care provision into a PC team may offer a broader spiritual care experience for patients receiving PC and begin to delineate expanded clinical roles for the palliative chaplain.

Vote for Me

Space was dim and cramped around the bed of the semiprivate room where we first encountered our patient, whom we’ll call Mr Robinson. Although it was nearly midday, curtains drawn haphazardly across the room blocked the late spring sunlight of Washington, DC. Mr Robinson had been poking through his lunch, disinterested and distracted. Suddenly becoming animated, he seemed to welcome the visit. He sat straight up, ran fingers through his usually slicked-back silver hair, and extended a hand. The grip was firm and earnest. We introduced ourselves as members of the palliative care team (H.G., A.K.) and the attending heart failure specialist (G.R.). Palliative care, we explained, is interdisciplinary care that focuses on symptom management, clarifying goals of care, and emotional and spiritual support for patients living with a serious progressive illness, like Mr Robinson’s advanced heart failure. We explained how, at our institution, the palliative care team meets all patients being evaluated for a left ventricular assist device as destination therapy (LVAD-DT), collaborating closely with the advanced heart failure team. This sounded agreeable to Mr Robinson; we proceeded with our assessment. As the visit was ending, Mr Robinson pointed a shaky finger in our direction. “Now listen carefully, please. I hope each of you vote for me.” We looked at each other, puzzled. “Some of the cardiologists explained to me earlier. The whole group is thinking about whether I’m a good candidate for the LVAD. I want you to know I’ll do whatever is necessary to get the LVAD. I’m following doctors’ instructions. I’m monitoring my fluid intake. I’m eating more so I can gain weight and get stronger. I’m a good candidate. And when you meet to decide, I want to know that I have your vote.” Newly developed medical technology may aim to lengthen life span and improve function or quality of life, but communication remains at the epicenter of effective health care delivery. How we say it matters as much as what we do.1 The weight of certain commonly used phrases continues to be reexamined by thoughtful clinicians. To talk of “withdrawing care” may be perceived as abandonment, when we really mean to discuss withdrawing specific technologies that are sustaining one or more organs.2 To tell a patient he is “failing chemotherapy” is not rational—the therapy, not the person, is ineffective.3 Similarly, when novel therapies are not appropriate for all individuals, medical culture may have slipped into another misapplied semantic of selectiveness. Considering the history of modern medicine, the way we clinically apply concepts of “candidacy” to patients appears relatively recent. In Aequanimitas, Sir William Osler employs the word “candidate” once, and then only to refer to selection of surgeons by a Canadian medical board.4 A brief MEDLINE search finds the earliest application of “candidate” to patients in 1954, in reference to patients undergoing a procedure to alleviate otosclerosis, with gradual increase in use through recent decades.5 In this case, Mr Robinson had understandably interpreted well-meaning conversations about his “eligibility” or “candidacy” for the LVAD as would be determined by a “selection committee.” He had concluded there would be a “vote.” Throughout his life, he had been evaluated by many “selection committees” and was always a “winner.” In high school he was evaluated and recruited to play college football. He later was a “good candidate” for the Marines and served his country. Failure, or not being selected by a “committee,” was something that happened to other people, not Mr Robinson. Like any hardworking candidate, he wanted to be chosen, and he sought the reassurance of his electorate, so to speak. Unfortunately, despite his insistent vigor, Mr Robinson was physically frail, cachectic, and deconditioned. Progressive renal failure was complicating his stage D congestive heart failure. When we returned late in the day, he had already learned from other physicians that he would not be receiving the LVAD. He was noticeably baffled, even angry. We tried to explain that this decision was not about his willpower or his personality—it was about trying to provide the care that seemed best and safest for him, given his clinical circumstances. He insisted he would work harder at rehabilitating his body and gaining muscle mass, as if his efforts could overcome the steady fade of his heart muscle. “I thought I was convincing,” he said. “I thought they would vote for me.” He looked dejected staring at the floor. We explained that all his care providers vote for him, in that we all wanted him to get the best and most appropriate care given these circumstances. We were in his corner, even if LVAD implantation was not an option. Despite these reassurances, he still exuded a sense of personal failure, as if the burden was his alone to wrestle his weary body into strong enough condition to endure a sternotomy and all of its potential complications. Mr Robinson was discharged home a few days later but was readmitted within the month, again in florid cardiogenic shock, this time with acutely worsening kidney failure. His continuous milrinone infusion was increased to a maximum rate. Ultrafiltration was initiated in hopes of sipping off excess fluid. Gingerly, without commitment or enthusiasm, conversations of permanent hemodialysis were introduced. But Mr Robinson’s blood pressure remained tenuous at best, and the consulting nephrologist was not optimistic. About a week later, with no sign of clinical improvement, the family meeting was scheduled to discuss A PIECE OF MY MIND

Consultation for total pain in high-risk obstetrics

Palliative care (PC) consultation rarely takes place in the clinical setting of high-risk obstetrics, where ‘total pain’ may be undermanaged. Here, we present a case of a young woman carrying twins and hospitalised for acute abdominal pain. Workup for her pain revealed non-viable fetal tissue positioned in the uterine horn; the remaining fetus was viable. Initial attempts to control the patient’s pain with strong parenteral opioids by the obstetrics team and the acute pain service failed. The PC service was consulted to assist. Applying a customary interdisciplinary approach in a novel PC clinical setting, the PC service was able to identify and attend to the patient’s physical, psychosocial and spiritual pain, resulting in an overall decrease in reported pain scores, decreased opioid requirement and a plan for preservation of the viable fetus.

Getting to the Heart of the Matter: A Regional Survey of Current Hospice Practices Caring for Patients With Heart Failure Receiving Advanced Therapies

Background: No guidelines exist regarding care for patients with advanced heart failure (HF) receiving hospice care while continuing advanced HF therapies such as left ventricular assist devices (LVADs) or continuous inotropes. Objective: We surveyed hospice providers in our tristate region to determine hospice demographics, current practices for care of patients with advanced HF, and perceived challenges of providing advanced HF therapies. Design: Cross-sectional survey of hospice clinical and administrative leaders. Results: Forty-six respondents representing 23 hospices completed the survey. Over half (27/46) held leadership administrative roles, and most (37/46) had more than 5 years of hospice experience. Although lack of experience and cost were cited as primary barriers to providing inotrope therapy in home hospice, about half of respondents (24/46) said they would manage inotropes. All participants said their respective hospices accept patients with implantable cardioverter-defibrillators; over half (28/46) said they accept patients with LVADs into hospice care. Lack of experience with LVADs was the most frequently cited barrier. Most participants were interested in training and support by an advanced HF program to facilitate hospice care of patients receiving these advanced therapies. General access to hospice services for patients with HF at their organization was considered adequate by 30 of 46 participants. Most (32/46) reported that referrals are made too late. Conclusions: Hospice specialists reported widely varied practice experiences caring for patients with HF receiving advanced therapies, noted specific challenges for care of these patients, and expressed a desire for targeted HF education.

Therapy First, Not the Patient?

This did not go well. We met Mr. Quincy in his cramped hospital room where he lay curled underneath musty wasabi green blankets. His daughter and her husband were already there. So was the cardiologist, Dr. Frederick, who had asked us, members of our hospital’s palliative care team, to join the family meeting that was about to begin. Our task was to help break the “bad news”: Mr. Quincy’s heart function had deteriorated significantly to an ejection fraction of 15%. He was weak, emaciated, and exhausted. He struggled with substance use disorder, a long history of depression, and was recently in the hospital with suicidal ideations. Before starting this downward journey of congestive heart failure, he felt like “a million bucks”; however, now he felt like one nickel. There was little left to offer in terms of curative disease-modifying therapy. “Thank you all for being here,” said Dr. Frederick. “Mr. Quincy, I want to talk to you about your heart failure. You’ve been here in the hospital now several weeks and we’ve been trying to get off this fluid, in your legs, in your lungs.” Mr. Quincy’s daughter nodded while he continued. “We’ve been changing your heart medications to make that easier. And this [he pointed to the IV pole] has been doing as much as it can to help your heart ‘squeeze’ better, but it’s not enough.” Hanging from the IV pole was a small translucent bag of the drug, milrinone, continuously dripping into Mr. Quincy to promote cardiac function. In our experiences with the heart failure specialist team it was common to see clinicians and patients alike describe the inotrope drug’s effect through hand motions: first a pulsatile grip around an imaginary basketball (without the milrinone) then again as if gripping an imaginary softball (with the milrinone). Mr. Quincy had been prescribed continuous milrinone at home for over 6 months now. Knowing the median extension of life with continuous milrinone is only 9 months from the time of drug initiation, we were not surprised with his dramatic decline. “I know I feel better than when I got here, doc,” said Mr. Quincy. “He’s going to do a better job with his diet from now on, right Dad?” added the daughter.

Reading the Room: Lessons on Holding Space and Presence

The following is a reflection on a patient interaction that draws attention to presence and holding space.

Failing better: a new paradigm of care

A professional colleague and advanced heart failure expert once noted to me that, Bheart failure is the cancer disease of cardiology.^ He went on to point out that, compared to patients with most solid cancers, patients with heart failure have significantly worse morbidity and mortality, are at risk for more frequent hospitalizations, and create a greater economic strain on the health system. Even as mechanical circulatory support (MCS) technology extends median survival by years, recipients still experience the distress of medical complications, chronic symptoms, and lifestyle changes. BAnd at some point,^ he continued, Bwe have to provide end-of-life care to all these patients...even the ones who get transplanted.^ As the heart failure epidemic grows, a growing awareness of the burdens of living with heart failure invites fresh perspectives on how we might best support these patients and their caregivers. If we can agree that the disease experience is far greater and more complex than simply pathophysiology, then efforts to serve these patients must extend beyond disease-modifying therapies.