Ki Y. Shin

Advance Directives and Do-Not-Resuscitate Orders in Patients with Cancer with Metastatic Spinal Cord Compression: Advanced Care Planning Implications

OBJECTIVES Communication about end-of-life decisions is crucial. Although patients with metastatic spinal cord compression (MSCC) have a median survival time of 3 to 6 months, few data are available concerning the presence of advance directives and do-not-resuscitate (DNR) orders in this population. The objective of this study was to determine presence of advance directives and DNR order among patients with MSCC. METHODS We retrospectively reviewed data concerning advance directives for 88 consecutive patients with cancer who had MSCC and required rehabilitation consultation at The University of Texas M. D. Anderson Cancer Center from September 20, 2005 to August 29, 2008. We characterized the data using univariate descriptive statistics and used the Fisher exact test to find correlations. RESULTS The mean age of this patient population was 55 years (range, 24-81). Thirty patients (33%) were female. Twenty patients (23%) had a living will, 27 patients (31%) had health care proxies, and 10 patients (11%) had either out-of-hospital DNR order and/or dictated DNR note. The median survival time for these patients was 4.3 months. CONCLUSION Despite strong evidence showing short survival times for MSCC patients, it seems many of these patients are not aware of the urgency to have an advance directive. This may be an indicator of delayed end-of-life palliative care and suboptimal doctor-patient communication. Using the catastrophic event of a diagnosis of MSCC to trigger communication and initiate palliative care may be beneficial to patients and their families.

Inpatient rehabilitation improved functional status in asthenic patients with solid and hematologic malignancies.

Objective: The aim of this study was to compare functional outcomes in asthenic patients with hematologic malignancies with those of asthenic patients with solid tumors after inpatient rehabilitation. We hypothesized that asthenic patients with hematologic malignancies are less likely than patients with solid tumors to make functional improvement after rehabilitation. Design: The records of 60 asthenic cancer patients (30 consecutive patients with solid tumors and 30 consecutive patients with hematologic malignancies) who underwent inpatient rehabilitation at a comprehensive cancer center between October 2005 and October 2007 were retrospectively reviewed. Patients with focal neurologic deficits were excluded. All patients admitted to the inpatient rehabilitation unit received 3 hrs of more of therapy per weekday. The main outcomes included total, motor, and cognitive Functional Independence Measure (FIM) scores, hospital and rehabilitation length of stay, and FIM efficiency. Results: The mean total FIM score significantly improved in patients with solid tumors (mean, 15; range, −6 to 38) and in patients with hematologic malignancies (mean, 17; range, −3 to 27); however, between-group differences in FIM scores were not significant (P = 0.31). The solid tumor patients were significantly older than the hematologic malignancy patients (71 ± 11 vs. 64 ± 12 yrs; P = 0.02), but the mean rehabilitation lengths of stay were the same for each group (9.5 days; P = 0.82). The mean FIM efficiency in the hematologic malignancy group was higher than that of the solid tumor group (1.9 vs.1.4; P = 0.049). Conclusions: Asthenic patients with solid tumors or hematologic malignancies could benefit from inpatient rehabilitation and make significant functional gain.

Inpatient cancer rehabilitation: the experience of a national comprehensive cancer center.

Objective: Cancer rehabilitation is an important but often underutilized treatment in the comprehensive care of the cancer patient. Cancer patients have varying levels of access to rehabilitation services. Acute inpatient, inpatient consultation-based, and outpatient-based cancer rehabilitation services have been described in the literature. We will discuss acute inpatient cancer rehabilitation and some of its outcomes at the University of Texas MD Anderson Cancer Center in Houston, TX, which is the only national comprehensive cancer center to have its own acute inpatient rehabilitation unit dedicated solely to cancer patients. Design: We retrospectively reviewed the inpatient medical records of consecutive inpatients admitted to the acute inpatient cancer rehabilitation unit from September 2008 to August 2009 for the following information: patient age, sex, primary tumor type, rehabilitation diagnoses, length of stay, discharge destination, and payer source. Results: From September 2008 to August 2009, the physical medicine and rehabilitation service at MD Anderson Cancer Center had 1098 inpatient consultations, of which 427 patients were admitted to the inpatient rehabilitation unit with a mean length of stay of 11 days. Of the 427 patients, 73 (17%) were patients with primary neurologic-based tumor, 71 (16%) were patients with hematologic-based tumors, 48 (11%) were sarcoma patients, 35 (8%) were gastrointestinal tumor patients, 27 (6%) were head and neck tumor patients, 25 (6%) were prostate and bladder cancer patients, 24 (6%) were lung cancer patients, 22 (5%) were melanoma patients, 20 (5%) were breast cancer patients, 15 (4%) were renal cancer patients, 14 (3%) were gynecologic cancer patients, and 53 (12%) were patients with other types of cancer. Of the 427 patients admitted to acute inpatient rehabilitation at MD Anderson Cancer Center, 324 (76%) were discharged home, 72 (17%) went back to acute care service, 15 (4%) were sent to a skilled nursing facility, 9 (2%) were discharged to palliative care, and 5 (1%) were discharged to a long-term acute care facility. Conclusions: An active inpatient rehabilitation unit within a national comprehensive cancer center receives referrals from patients with a wide variety of tumor types and is able to successfully discharge home 76% of its patients.

Prognostic Value of Heart Rate Variability in Patients with Cancer

Introduction: Previous studies have shown that autonomic dysfunction is associated with shorter survival in patients with advanced cancer. We examined the association between heart rate variability, a measure of autonomic function, and survival in a large cohort of patients with cancer. Methods: We retrospectively examined the records of 651 patients with cancer who had undergone ambulatory electrocardiogram monitoring for 20 to 24 hours. Time domain heart rate variability (SD of normal-to-normal beat interval [SDNN]) was calculated using power spectral analysis. Survival data were compared between patients with SDNN ≥ 70 milliseconds (Group 1, n = 520) and SDNN < 70 milliseconds (Group 2, n = 131). Results: Two groups were similar in most variables, except that patients in group 2 had a significantly higher percentage of male patients (P = 0.03), hematological malignancies (P = 0.04), and use of non–selective serotonin reuptake inhibitor antidepressants (P = 0.04). Patients in group 2 had a significantly shorter survival rate (25% of patients in group 2 died by 18.7 weeks vs. 78.9 weeks in group 1 patients; P < 0.0001). Multivariate analysis showed that SDNN < 70 milliseconds remained significant for survival (hazard ratio 1.9 [95% confidence interval: 1.4–2.5]) independent of age, cancer stage, and performance status. Conclusion: The presence of cancer in combination with decreased heart rate variability (SDNN < 70 milliseconds) is associated with shorter survival time.

Frequency and Reasons for Return to the Primary Acute Care Service Among Patients With Lymphoma Undergoing Inpatient Rehabilitation

To assess the frequency and risk factors for return to the primary acute care service among patients with lymphoma undergoing inpatient rehabilitation.

Botulinum Toxin Injection and Phenol Nerve Block for Reduction of End-of-Life Pain

BACKGROUND Injectable antispasticity agents have been utilized for the reduction of pain. However, there are no reports of its use for end-of-life pain. PATIENT CASE A 62-year-old female with a history of progressive left frontotemporal glioblastoma status post gross total resection, radiation, and chemotherapy presented to the physical medicine and rehabilitation (PM&R) clinic for management of spastic quadriplegia and pain. At the time of presentation to the PM&R clinic she was no longer eligible for further cancer treatment. The patient had been declining neurologically with cognitive changes, weakness, and increasing spasticity. The patient had an Edmonton Symptom Assessment Scale (ESAS) pain score of 8/10 at her visit, as reported by her husband. She exhibited mild to moderate spasticity during the exam. Cognitively, she was unable to follow commands and would fluctuate between being awake for a few minutes and sleeping during the exam. She was not on any oral muscle relaxants and none were started due to her state of hypoarousal. Nine days after the initial consultation she received 700 units of onabotulinum toxin into her bilateral upper limbs and left thigh and a phenol nerve block to her left tibial nerve. At a follow-up visit 28 days later in the palliative care clinic, the ESAS pain score was 0. The patient died 51 days post-injection. CONCLUSION The case report demonstrates the use of injectable antispasticity agents in the reduction of end-of-life pain in a glioblastoma patient.

An Analysis of Inpatient Rehabilitation Approval Among Private Insurance Carriers at a Cancer Center

Acute inpatient rehabilitation is often used by cancer patients to assist with discharge home and/or preparation for further treatment. Private insurance patients often require approval before transfer to acute inpatient rehabilitation.

Postacute Care in Cancer Rehabilitation

Acute care is usually associated with disease progression, treatments for cancer, and medical comorbidities. Patients with cancer may develop sudden functional deficits that require rehabilitation. Some of these patients benefit from acute rehabilitation, others benefit from subacute rehabilitation. After acute rehabilitation, continuous care for these patients has not been well described. Three studies are presented to demonstrate that cancer rehabilitation is a continuous process. Rehabilitation professionals should know how to detect fall risk, monitor symptoms, and render symptom management. Patients with cancer often require rehabilitation services during their entire disease trajectory.

Poster 26: Acute Inpatient Rehabilitation With the Assistance of a Leukemia-trained Hospitalist at a National Comprehensive Cancer Center

Disclosures: D. M. Brooks, None. Patients or Programs: A 69-year-old man who underwent bilateral subthalamic bilateral deep brain stimulator (DBS) placement for medically refractory Parkinson disease. Program Description: This patient had a past medical history of depression, hyperlipidemia, and advanced medically refractory Parkinson disease. On postoperative day 4 from deep brain stimulator placement, he was transferred to acute inpatient neurorehabilitation where he presented with episodic agitation, poor safety awareness, paranoia and was noted to express paranoid delusions. Neuropsychological evaluation revealed Capgras syndrome, centered mostly around the patient’s wife who visited daily. Setting: Acute rehabilitation hospital. Results: For control of agitation and delusions, risperidone therapy was initiated. Dosage was titrated up to 4 mg/day until the delusions were dampened. On postoperative day 18, he was discharged home with his wife from acute inpatient neurorehabilitation with resolved agitation but continued, albeit dampened, delusions. In the outpatient setting, risperidone was subsequently tapered off with complete resolution of delusions over 2 months. Discussion: Capgras syndrome is the delusional belief that a person significant to the patient such as a spouse, friend or family member, is an imposter or an identical appearing double. It has been hypothesized that the syndrome is a result of a disconnection between the recognition of a face and the emotional reaction to it. This patient, when interviewed, in fact stated that he knew it was not his wife because he would feel something when he saw her, and he felt nothing when this “imposter” would visit. Conclusions: Deep brain stimulator placement has been associated with transient postoperative neuro-cognitive changes. To our knowledge there have been no specific reports of Capgras syndrome.