Comparison of direct medical care costs between patients receiving care in a designated palliative care unit and the usual care units.

AIM: The need for palliative services is increasing throughout Thailand. A few palliative care units have been established in the nation so far. An economic evaluation of palliative care units has never been explored. This study compared between the medical costs of terminally ill patients receiving palliative care in a palliative care unit and the usual care units during their final admissions. METHODS: This study was a retrospective observational study comparing the costs of care for patients who died in a tertiary hospital. The study group comprised patients who died in a palliative care unit, then matched with deceased patients from other units by diagnosis-related groups. Patients not indicating of having received palliative care in the medical records were excluded. The direct medical costs of the patients' care and their data were collected from the finance department database and by medical chart review. Data were entered into the SPSS statistical database. The costs of the control group were calculated from the day when palliative care was initiated RESULTS: The total cost of care was significantly lower in the palliative care unit by 45 percent. The cost reduction notably was from the shorter length of stay and lower expenditure on medication and investigations in the palliative care unit. The utilization of aggressive treatment was higher in the usual units. CONCLUSIONS: The palliative care unit was associated with cost savings in caring for terminally ill patients in a tertiary hospital in Thailand.

Comparison of feasibility between hypodermoclysis and intravenous hydration among palliative care patients in Thailand.

BACKGROUND: Hypodermoclysis is a method of subcutaneous fluid administration. It has been used to treat palliative patients safely and effectively. However, the use of subcutaneous hydration is often overlooked. AIM: This study aimed to compare the feasibility, pain experience and acceptability between subcutaneous and intravenous hydration in a hospital setting. METHODS: A prospective, randomised clinical trial was conducted. Patients requiring fluid administration were randomly allocated an intravenous or subcutaneous route. Patients' pain score, satisfaction and acceptance levels were collected. The difficulty score of the needle insertion and acceptance scores from nurses were recorded. FINDINGS: A total of 26 patients were enrolled. The difficulty scores and patients' pain scores were significantly lower in the subcutaneous group. The satisfaction and acceptance levels of the patients and nurses were similar in both groups. No systemic side-effects were found in either group. CONCLUSION: Hypodermoclysis was acceptable and satisfying to patients and nurses. It was less painful than the intravenous route.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand.

BACKGROUND: The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality. METHODS: A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included. RESULTS: A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was 'cannot control symptoms' (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality. CONCLUSION: The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients.

PURPOSE: The aim of this study is to establish the prevalence, associated factors, and clinical impact of delirium in newly referred palliative care patients and the percentage of delirium diagnoses missed by primary medical teams. METHODS: Newly referred palliative care patients were evaluated and were reviewed for possible associated factors of delirium. Univariable and multivariable analysis were used to identify associated factors. Median overall survival and survival curves were analyzed. The percentage of missed diagnosis in IPD patients was identified. RESULTS: We included 350 palliative care patients. Nearly all patients had cancer diagnosis (96.6%). The overall prevalence of delirium was 44.0%. The independent associated factors of delirium were age ≥ 63 years (adjusted odds ratio [aOR], 7.0; 95% CI, 2.2-22.9), palliative performance scale ≤ 20% (aOR, 54.5; 95% CI, 13.1-228.0), brain metastasis (aOR, 15.6; 95% CI, 3.7-66.7), urinary tract infection (aOR, 18.8; 95% CI, 4.7-75.5), sepsis (aOR, 59.0; 95% CI, 4.4-797.8), hyponatremia (aOR, 8.8; 95% CI, 2.6-29.8), and hypercalcemia (not applicable). Interestingly, opioids and benzodiazepines were not associated with delirium. Delirious patients had significantly shorter survival (median survival 11 days). Delirium diagnoses were missed for 76.1%. CONCLUSION: Nearly half of the palliative care patients had delirium, which was associated with noticeably short survivals. We identified the independent factors associated with the delirium. Despite having a remarkably high prevalence rate and being a well-known poor prognostic factor, there was still a very high rate of missed delirium diagnoses. Effective, routine, delirium screening of palliative care patients needs to be emphasized.

Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients.

BACKGROUND: Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale-Thai version (MDAS-T) in PC patients. MATERIALS AND METHODS: The MDAS was translated into Thai. Content validity, inter-rater reliability, and internal consistency were explored. The construct validity of the MDAS-T was analyzed using exploratory factor analysis. Instrument testing of the MDAS-T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU-T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded. RESULTS: The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one-factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93-0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS-T were 0.92 (0.85-0.96) and 0.90 (0.82-0.94), respectively, with a cutoff score of 9, whereas the CAM-ICU-T yielded 0.58 (0.48-0.67) and 0.98 (0.93-0.99), respectively. The median MDAS-T assessment time was 5 minutes. CONCLUSION: This study established and validated the MDAS-T as a good and feasible tool for delirium screening and severity rating in PC settings. IMPLICATIONS FOR PRACTICE: Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS-T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population.

Effects of single shot femoral nerve block combined with intrathecal morphine for postoperative analgesia: a randomized, controlled, dose-ranging study after total knee arthroplasty.

OBJECTIVE: Pain after total knee arthroplasty (TKA) is severe, thus adequate pain control can be a challenge. Intrathecal morphine (ITM) provides excellent postoperative analgesia for TKA, but may have side effects. Femoral nerve block (FNB) also has been used for postoperative analgesia in TKA. We examined postoperative analgesia efficacy and side effects of ITM combined with single shot femoral nerve block (SSFNB) after TKA, over the dosage range of 0.0 to 0.3 mg. MATERIAL AND METHOD: Sixty patients undergoing elective TKA received SSFNB (0.5% bupivacaine 20 ml) and spinal anesthesia with 15 mg of hyperbaric bupivacaine (0.5% Heavy Marcaine) were included in this study. They were randomized to receive ITM (0, 0.1, 0.2, and 0.3 mg). A patient-controlled analgesia (PCA) device provided additional intravenous morphine. Morphine consumption, pain score, and side effects were recorded at 0, 1, 4, 8, 12, and 24 hour postoperative. Patient satisfaction was rated at the 24-hour postoperative visit. RESULTS: Morphine consumption was significant higher in 0 mg ITM group (control) than other groups, but there was no difference between ITM groups. Pain score was significant lower in 0.3 mg ITM group compared to 0 mg at 1 hour (0.5 vs. 3.5, respectively; p-value = 0.013) and 4 hour (1.5 vs. 4.5, respectively; p-value = 0.037) postoperative period Side effects were not different in all groups. CONCLUSION: The present study concluded that, low-dose ITM combination with SSFNB provided good pain relief with low side effects and reduced morphine consumption during the first 24 hours post TKA.

Systematic review of questionnaires measuring patient satisfaction in ambulatory anesthesia.

BACKGROUND: Patient satisfaction has become an important component of quality improvement in ambulatory anesthesia services. However, it is difficult to measure due to its subjective and complex psychological construct. Psychometric methodology has been successfully used to evaluate this outcome. The authors conducted a systematic review to evaluate questionnaires to measure patient satisfaction with ambulatory anesthesia. METHODS: A systematic literature search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, HAPI, PsycINFO, and Dissertation Abstracts was performed to identify studies on questionnaires evaluating patient satisfaction after ambulatory anesthesia. The authors included the articles that used multiple-item questionnaires, and the questionnaires were assessed with the strategy of psychometric questionnaire construction, validity, reliability, and acceptability. RESULTS: The authors scanned 131 articles yielded by our search strategy. Eleven articles were included in the study. Two questionnaires, IOWA Satisfaction with Anesthesia Scale and Evaluation du Vecu de I'Anesthesie Generale, fulfilled the criteria, but the latter was not developed specifically for ambulatory anesthesia, whereas Iowa Satisfaction with Anesthesia Scale was designed only for monitored anesthesia patients. CONCLUSIONS: In a large number of trials, patient satisfaction has been evaluated using overall satisfaction or nonvalidated questionnaires. Only a few studies have developed questionnaires with rigorous psychometric methods to measure patient satisfaction with anesthesia care. At this time, there is still no valid or reliable questionnaire for measuring patient satisfaction in ambulatory anesthesia. Further study should be conducted to develop standardized instruments to measure this outcome.