Linda Ganzini

Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management

AbstractBACKGROUND: To improve pain management, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters. OBJECTIVE: To measure the initiative’s impact on the quality of pain management. DESIGN: We retrospectively reviewed medical records at a single medical center to compare providers’ pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (≥4) during a postimplementation visit. PARTICIPANTS: Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic. MEASUREMENTS: We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative. RESULTS: The quality of pain care was unchanged between visits before and after the pain initiative (P>.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit. CONCLUSIONS: Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

Correlates of suffering in amyotrophic lateral sclerosis.

Objectives: 1) To determine the prevalence of pain, suffering, poor quality of life, depression, and hopelessness in people with ALS, and the correlates of suffering and poor quality of life; 2) to analyze the relationship between pain, suffering, quality of life, and attitudes toward life-sustaining medical treatment and physician-assisted suicide; and 3) to determine concordance between patients with ALS and their caregivers in rating the patients’ pain, quality of life, and suffering. Methods: Subjects completed a single interview. We measured the subject’s pain, quality of life, suffering, hopelessness, depression, social support, perception of burden to others, level of disability, desire for life-sustaining medical treatment, and interest in assisted suicide. Caregivers also rated the patient’s quality of life, pain, and suffering. Results: A total of 100 subjects with ALS and 91 caregivers participated. Suffering was rated as 4 or greater on a six-point scale by 20% of subjects with ALS, and 19% rated their pain as 4 or greater on a six-point scale. Eleven percent had clinical depression. Physicians frequently failed to recognize and treat pain and depression. The correlates of suffering were increasing pain, hopelessness, and level of disability. The correlates of poor quality of life were poor social support and increasing hopelessness. The correlation between subjects’ and caregivers’ rating of the patient’s suffering was r = 0.47. There was no relationship between subjects’ ratings of pain, suffering, and quality of life, and their interest in life-sustaining treatment or physician-assisted suicide. Conclusion: Many patients with ALS suffer, and their suffering is correlated to pain and hopelessness. Physicians caring for patients with ALS frequently fail to recognize and treat their patients’ pain and depression.

The final month of life in patients with ALS

ObjectiveTo study the health care experiences and palliative care needs of patients with ALS in their final month of life. MethodsCaregivers of decedent patients with ALS completed a single survey focused on the final month of life. They reported the patients’ physical and emotional symptoms, preferences for end-of-life care, completion of advance directives, and preparation for death. The caregiver reported which life-sustaining treatments were administered, withheld, or withdrawn; whether the patient was enrolled in hospice; and their own satisfaction with the patient’s medical care. ResultsFifty caregivers completed the survey. Caregivers reported that the most common symptoms in the last month of life included difficulty communicating (62%), dyspnea (56%), insomnia (42%), and discomfort other than pain (48%). Pain was both frequent and severe. One-third of caregivers were dissatisfied with some aspect of symptom management. Caregivers reported an advance directive was completed by 88% of patients and the patients’ goals of care were honored by 88% of health care practitioners. Two-thirds of patients were enrolled in hospice. Compared to nonhospice patients, hospice patients were significantly more likely to: 1) die in their preferred location; 2) die outside the hospital; and 3) receive morphine. Most caregivers reported that their loved one was at peace, and prepared for and was accepting of death. ConclusionsCaregivers report that many patients with ALS still experience distressing physical symptoms in the last month of life, despite enrollment in hospice. Most patients with ALS, however, anticipate and plan for their deaths and have their wishes respected.

Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey

Objective To determine the prevalence of depression and anxiety in terminally ill patients pursuing aid in dying from physicians. Design Cross sectional survey. Setting State of Oregon, USA. Participants 58 Oregonians, most terminally ill with cancer or amyotrophic lateral sclerosis, who had either requested aid in dying from a physician or contacted an aid in dying advocacy organisation. Main outcome measures Diagnosis of depression or anxiety according to the hospital anxiety and depression scale and the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders. Results 15 study participants met “caseness” criteria for depression, and 13 met criteria for anxiety. 42 patients died by the end of the study; 18 received a prescription for a lethal drug under the Death with Dignity Act, and nine died by lethal ingestion. 15 participants who received a prescription for a lethal drug did not meet criteria for depression; three did. All three depressed participants died by legal ingestion within two months of the research interview. Conclusion Although most terminally ill Oregonians who receive aid in dying do not have depressive disorders, the current practice of the Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug.

Depression and Mortality in Medically Ill Older Adults

OBJECTIVE: To determine if major depressive disorder influences the survival of older, medically ill veterans.

Depression in the Elderly: Effect on Patient Attitudes toward Life-Sustaining Therapy

Objective: To determine the effect of depression on preferences for life‐sustaining therapy in older persons.

Screening for Alcohol Use Disorders in the Nursing Home

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM‐III‐R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM‐III‐R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST‐G, and the two‐question instrument developed by Cyr and Wartman.

Artificial nutrition and hydration at the end of life: ethics and evidence.

The case of Terri Schiavo resulted in substantial media attention about the use of artificial nutrition and hydration (ANH) especially by percutaneous endoscopic gastrostomy (PEG). In this article, I review ethical and legal principles governing decisions to choose or forgo ANH at the end of life, including issues of autonomy and decision-making capacity, similarities and differences between ANH and other medical treatments, the role of proxies when patients lack decision-making capacity, and the equivalence of withholding and withdrawing treatment. Evidence for palliative or life-sustaining benefits for ANH are reviewed in three disease processes: amyotrophic lateral sclerosis (ALS), cancer, and dementias, including Alzheimers disease. Although more recent studies suggest a possible palliative role for ANH in ALS and terminal cancer, feeding tubes do not appear to prolong survival or increase comfort in advanced dementia of the Alzheimers type.

Neuropsychiatric adverse effects of antiparkinsonian drugs. Characteristics, evaluation and treatment

SummaryParkinson’s disease (PD) is a progressive neurological condition that causes considerable disability in the elderly. Drugs used to treat PD, such as levodopa, offer symptomatic relief but often have neuropsychiatric adverse effects, most prominently psychosis and delirium. Aged patients and those with dementia are particularly vulnerable to these adverse effects. Evaluating PD patients with drug-induced neuropsychiatric adverse effects is made difficult by their complex clinical presentations.The treatment of drug-induced psychosis and delirium begins with manipulating the antiparkinsonian drug regimen, but this frequently worsens motor function. Atypical antipsychotics such as clozapine have been successfully employed to treat the psychosis without worsening the motor disability. Patient intolerance of clozapine therapy has prompted open-label studies with newer agents such as risperidone, remoxipride, zotepine, mianserin and ondansetron.

Why Oregon Patients Request Assisted Death: Family Members’ Views

BACKGROUNDPhysician assisted death (PAD) was legalized through Oregon’s Death with Dignity Act in 1994 and enacted in 1997.OBJECTIVEThe objective of this paper was to learn from family members why their loved ones requested PAD.DESIGNThis study used the cross-sectional survey.PARTICIPANTSParticipants of this study included family members of 83 Oregon decedents who made explicit requests for legalized PAD before their deaths, including 52 decedents who received prescriptions for a lethal medication and 32 who died of PAD.MEASUREMENTSFamily members rated the importance of 28 possible reasons their loved ones requested PAD on a 1–5 Likert scale, with higher scores representing greater importance.RESULTSAccording to family members, the most important reasons that their loved ones requested PAD, all with a median score of 4.5 or greater, were wanting to control the circumstances of death and die at home, and worries about loss of dignity and future losses of independence, quality of life, and self-care ability. No physical symptoms at the time of the request were rated higher than a median of 2 in importance. Worries about symptoms and experiences in the future were, in general, more important reasons than symptoms or experiences at the time of the request. According to family members, the least important reasons their loved ones requested PAD included depression, financial concerns, and poor social support.CONCLUSIONSInterventions that help patients maintain control, independence, and self-care in a home environment may be effective means of addressing serious requests for PAD.