Palliative Care in Advanced Liver Disease: Similar or Different Palliative Care Needs in Patients with a Prospect of Transplantation? Prospective Study from a Portuguese University Hospital and Transplantation Center.

Background and Aims: End-stage liver disease (ESLD) is an important cause of morbidity and mortality, comparable to a large extent to other organ insufficiencies. The need for palliative care (PC) in patients with ESLD is high. In Portugal, in the only identified study, more than 80% of patients hospitalized with ESLD had criteria for PC. No results specified which needs they identified or their transplantation prospect status. Methods: Prospective observational study including 54 ESLD patients who presented to a university hospital and transplantation center, between November 2019 and September 2020. Assessment of their PC needs through the application of NECPAL CCOMS-ICO© and IPOS, considering their transplantation perspective status. Results: Of the 54 patients, 5 (9.3%) were on active waiting list for transplantation and 8 (14.8%) under evaluation. NECPAL CCOMS-ICO© identified 23 patients (n = 42.6%) that would benefit from PC. Assessment of PC needs by clinicians, functional markers and significant comorbidities were the most frequent criteria (47.8%, n = 11). IPOS also revealed a different sort of needs: on average, each patient identified about 9 needs (8.9 ±2.8). Among the symptoms identified, weakness (77.8%), reduced mobility (70.3%), and pain (48.1%) stood out, as well as the psychoemotional symptoms of depression (66.7%) and anxiety (77.8%). There were no significant differences between the subgroups of patients analyzed. Only 4 patients (7.4%) were followed by the PC team. Conclusion: All the ESLD patients included, independently of the group they belonged to, presented with PC needs. No significant differences between the subgroups of patients were identified, confirming that even patients with a transplantation prospect have important needs for PC.

Introdução e objetivos: A doença hepática avançada (DHA) é uma causa importante de morbilidade e mortalidade, comparável em grande medida a outras insuficiências de órgão. A necessidade de cuidados paliativos (CP) em doentes com DHA é elevada. Em Portugal, no único estudo identificado até ao momento, mais de 80% dos doentes hospitalizados com DHA apresentavam critérios para CP. Não foram especificadas que necessidades de CP nem a perspetiva de transplante dos referidos doentes, que com o presente estudo se pretende ajudar a esclarecer. Métodos: Estudo prospectivo observacional incluindo 54 doentes com DHA assistidos num hospital universitário e centro de transplante, entre novembro de 2019 e setembro de 2020. Avaliação das necessidades de CP por meio da aplicação do NECPAL CCOMS-ICO© e IPOS, considerando a sua perspectiva de transplante. Resultados: Dos 54 doentes, cinco (9,3%) estavam em lista de espera ativa para transplante e oito (14,8%) em avaliação. O NECPAL CCOMS-ICO© identificou 23 doentes (n = 42,6%) que beneficiariam de CP. A avaliação das necessidades de CP por médicos, os marcadores funcionais e as comorbidades significativas foram os critérios mais frequentes (47,8%, n = 11). O IPOS também revelou diversas necessidades de CP: em média, cada doente identificou cerca de 9 necessidades (8,9 + −2,8). Entre os sintomas identificados, destacaram-se a fraqueza (77,8%), a mobilidade reduzida (70,3%) e a dor (48,1%), bem como os sintomas psicoemocionais de depressão (66,7%) e ansiedade (77,8%). Não houve diferenças significativas entre os subgrupos de doentes analisados. Apenas 4 doentes (7,4%) foram acompanhados pela equipa intra-hospitalar de CP. Conclusão: Todos os doentes com DHA incluídos, independentemente do grupo a que pertenciam, apresentaram necessidades de CP. Não foram identificadas diferenças significativas entre os subgrupos de doentes, confirmando que mesmo os doentes com perspectiva de transplante têm importantes necessidades de CP.

Prevalence of constipation on an internal medicine ward.

In hospitalized patients the prevalence of constipation is high, especially among elderly patients. Constipation impacts significantly the quality of life of patients and is associated with increased morbidity and length of hospital stay. This retrospective observational study intended to identify the prevalence of constipation in patients hospitalized in an internal medicine ward. In a sample of 80 patients, the median age was 79 years and 53% (n = 42) were women. We identified constipation in 68% (n = 56) of the patients during hospitalization. The medical team prescribed treatment only to 70% of those patients. Constipation was responsible for delirium in 11% of patients and 5% suffered urinary retention. This study shows constipation is prevalent among patients admitted in an internal medicine ward. Systematic assessment of this problem can improve the overall care of the patients, alleviate symptoms, and prevent complications.

Palliative medicine in the emergency department: symptom control and aggressive care.

OBJECTIVES: Identifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care. METHODS: We conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson's Index. RESULTS: 384 adults died at the ED (median age 82 (IQR 72-89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2-4) vs 3 (2-5)), p=0.082. CONCLUSIONS: Nearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.

Best Supportive Care of the Patient with Oesophageal Cancer.

BACKGROUND: Oesophageal cancer patients have poor survival, and most are unfit for curative or systemic palliative treatment. This article aims to review the best supportive care for oesophageal cancer, focusing on the management of its most frequent or distinctive symptoms and complications. METHODS: Evidence-based review on palliative supportive care of oesophageal cancer, based on Pubmed search for relevant clinical practice guidelines, reviews and original articles, with additional records collected from related articles suggestions, references and societies recommendations. RESULTS: We identified 1075 records, from which we screened 138 records that were related to oesophageal cancer supportive care, complemented with 48 additional records, finally including 60 records. This review summarizes the management of oesophageal cancer-related main problems, including dysphagia, malnutrition, pain, nausea and vomiting, fistula and bleeding. In recent years, several treatments have been developed, while optimal management is not yet standardized. CONCLUSION: This review contributes toward improving supportive care and decision making for oesophageal cancer patients, presenting updated summary recommendations for each of their main symptoms. A robust body of evidence is still lacking, and the best supportive care decisions should be individualized and shared.

Palliative Care in End-Stage Liver Disease Patients Awaiting Liver Transplantation: Review.

INTRODUCTION: End-stage liver disease (ESLD) is the advanced phase of most liver diseases. The cure is liver transplantation (LT), only available for a minority of patients. This review summarizes the evidence regarding palliative care (PC) in ESLD patients awaiting LT. METHODS: Review of the literature available in Medline, Scopus and Web of Knowledge, with keywords ESLD and PC. RESULTS: Fifteen of the 230 articles reviewed met the inclusion criteria. Ten main themes were addressed: symptom burden; perspectives of life-sustaining treatment and comfort for patients, families and health professionals; goals of care discussions; patient and family needs; quality of life; PC and survival; referral to PC, barriers and opportunities; integration of PC; outpatient care and cost-effectiveness analysis. The referral of patients to PC was only evaluated in a few studies, all of which reported low referral rates. Better knowledge of how PC professionals can support other professionals was considered important, and also better ways to integrate PC were considered essential. CONCLUSION: ESLD patients awaiting LT have a significant need for PC and, despite the insufficient response, were reported to benefit from this type of care. Future research is essential to determine the means to overcome barriers and better integrate PC for ESLD patients awaiting LT.

INTRODUÇÃO: A doença hepática avançada (DHA) corresponde à fase mais avançada das doenças hepáticas. O transplante hepático (TH) é o tratamento curativo, disponível apenas para uma minoria de doentes. Esta revisão sumariza a evidência sobre cuidados paliativos (CP) em doentes com DHA que aguardam TH. MÉTODOS: Revisão da literatura existente na Medline, Scopus e Web of Knowledge. Palavras chave pesquisadas CP e DHA. RESULTADOS: Quinze dos 230 artigos encontrados cumpriram critérios de inclusão. Dez temáticas foram abordadas: carga sintomática; discussão de objectivos de cuidados; perspectivas sobre tratamentos de suporte artificial e conforto; necessidades do doente e família; qualidade de vida; CP e impacto no prognóstico; referenciação para CP, barreiras e oportunidades; integração dos CP; cuidados de ambulatório e análises de custo-benefício. Poucos estudos avaliaram a referenciação para CP, todos com baixas taxas. Mais conhecimento e formação dos profissionais que acompanham doentes com DHA parece ser necessário, bem como, melhor articulação entre os diferentes intervenientes. CONCLUSÃO: Doentes com DHA que aguardam TH apresentam importantes necessidades de CP. Apesar da insuficiente resposta a este nível, parecem beneficiar deste tipo de cuidados. Estudos futuros que clarifiquem como ultrapassar as barreiras e a melhor integração dos CP nos doentes que aguardam TH são essenciais.

Palliative approach in acute neurological events: a five-year study

SUMMARY INTRODUCTION Acute neurological illness often results in severe disability. Five-year life expectancy is around 40%; half the survivors become completely dependent on outside help. OBJECTIVE Evaluate the symptoms of patients admitted to a Hospital ward with a diagnosis of stroke, subarachnoid hemorrhage or subdural hematoma, and analyze the role of an In-Hospital Palliative Care Support Team. MATERIAL AND METHODS Retrospective, observational study with a sample consisting of all patients admitted with acute neurological illness and with a guidance request made to the In-Hospital Palliative Care Support Team of a tertiary Hospital, over 5 years (2012-2016). RESULTS A total of 66 patients were evaluated, with an age median of 83 years old. Amongst them, there were 41 ischaemic strokes, 12 intracranial bleedings, 12 subdural hematomas, and 5 subarachnoid hemorrhages. The median of delay between admission and guidance request was 14 days. On the first evaluation by the team, the GCS score median was 6/15 and the Palliative Performance Scale (PPS) median 10%. Dysphagia (96.8%) and bronchorrhea (48.4%) were the most prevalent symptoms. A total of 56 patients had a feeding tube (84.8%), 33 had vital sign monitoring (50.0%), 24 were hypocoagulated (36.3%), 25 lacked opioid or anti-muscarinic therapy for symptom control (37,9%); 6 patients retained orotracheal intubation, which was removed. In-hospital mortality was 72.7% (n=48). DISCUSSION AND CONCLUSION Patients were severely debilitated, in many cases futile interventions persisted, yet several were under-medicated for symptom control. The delay between admission and collaboration request was high. Due to the high morbidity associated with acute neurological illness, palliative care should always be timely provided.

RESUMO INTRODUÇÃO Eventos neurológicos agudos resultam frequentemente em incapacidade grave que impede o doente de participar ativamente nas decisões do seu próprio tratamento. A sobrevida a cinco anos ronda os 40%; metade dos sobreviventes fica dependente de terceiros. Objetivo Avaliar a sintomatologia de doentes internados com acidente vascular cerebral (AVC), hemorragia subarcnoideia (HSA) ou subdural (HSD) e analisar a intervenção de uma Equipe Intra-Hospitalar de Suporte em Cuidados Paliativos (EIHSCP). MATERIAL E MÉTODOS Estudo retrospetivo observacional dos doentes com diagnóstico principal de evento neurológico agudo com pedido de colaboração à EIHSCP, num hospital terciário, durante cinco anos (2012-2016). RESULTADOS Avaliados 66 doentes, com média de idade de 83 anos. Destacam-se 41 AVC isquêmicos, 12 hemorrágicos, 12 HSD e 5 HSA. A média da demora entre internamento e pedido de colaboração à EIHSCP foi de 14 dias. Na primeira observação, a média na escala de coma de Glasgow foi de 6/15 e na Palliative Performance Scale (PPS) foi de 10%. Disfagia (96,8%) e broncorreia (48,4%) foram os sintomas mais frequentes. A maioria dos doentes (56/66) mantinha sonda nasogástrica (84,8%); 33 encontravam-se em monitorização cardiorrespiratória (50,0%); 24 estavam sob hipocoagulação (36,3%); 25 necessitavam de opioide e antimuscarínico que não estavam prescritos (37,9%); seis tinham tubo orotraqueal, que foi retirado. A mortalidade intra-hospitalar foi de 72,7% (n=48). DISCUSSÃO E CONCLUSÃO Destaca-se o estado debilitado dos doentes; em muitos casos, intervenções fúteis persistiam, mas várias foram submedicadas para o controle dos sintomas. Verificou-se um tempo de espera elevado até o pedido de colaboração. Pela elevada morbilidade associada a esses eventos, cuidados paliativos diferenciados deveriam ser oferecidos no tempo adequado.

Palliative approach in acute neurological events: a five-year study.

INTRODUCTION: Acute neurological illness often results in severe disability. Five-year life expectancy is around 40%; half the survivors become completely dependent on outside help. OBJECTIVE: Evaluate the symptoms of patients admitted to a Hospital ward with a diagnosis of stroke, subarachnoid hemorrhage or subdural hematoma, and analyze the role of an In-Hospital Palliative Care Support Team. MATERIAL AND METHODS: Retrospective, observational study with a sample consisting of all patients admitted with acute neurological illness and with a guidance request made to the In-Hospital Palliative Care Support Team of a tertiary Hospital, over 5 years (2012-2016). RESULTS: A total of 66 patients were evaluated, with an age median of 83 years old. Amongst them, there were 41 ischaemic strokes, 12 intracranial bleedings, 12 subdural hematomas, and 5 subarachnoid hemorrhages. The median of delay between admission and guidance request was 14 days. On the first evaluation by the team, the GCS score median was 6/15 and the Palliative Performance Scale (PPS) median 10%. Dysphagia (96.8%) and bronchorrhea (48.4%) were the most prevalent symptoms. A total of 56 patients had a feeding tube (84.8%), 33 had vital sign monitoring (50.0%), 24 were hypocoagulated (36.3%), 25 lacked opioid or anti-muscarinic therapy for symptom control (37,9%); 6 patients retained orotracheal intubation, which was removed. In-hospital mortality was 72.7% (n=48). DISCUSSION AND CONCLUSION: Patients were severely debilitated, in many cases futile interventions persisted, yet several were under-medicated for symptom control. The delay between admission and collaboration request was high. Due to the high morbidity associated with acute neurological illness, palliative care should always be timely provided.

[Patient centered practice in internal medicine]. / Gestos e atitutes em medicina centrada no doente num serviço de medicina interna.

We made a cross-sectional study aimed at 50 professionals (18 doctors, 32 nurses) of a tertiary hospital Internal Medicine (IM) ward, focusing the relevant knowledge in various areas of Patient-Centered Care in Chronic Disease: symptom control, pharmacology and palliative prognostic discussion. Almost 98% believe that most patients need strategies for symptomatic care, which died in hospital in considerable suffering (68%). Provision of palliative care in the community was rarely established with the primary health team. 90% were favourable on the creation of a hospital palliative care team. Around 57% find essential to prognosticate before thinking about mitigation strategies. While 75% of professionals had already discussed end-of-life directives with, at least, one patient, only one case could be formalized in writing. The rate of use of scales for assessing the intensity of pain was less than 50% and 38% did not indicate major opioids for the treatment of moderate intensity pain. These were considered contra-indicated for relief of dyspnoea in chronic obstructive pulmonary disease by 20% of professionals and 55% of those were unaware that its use and titration is governed by the same principles used in pain control. Around 44% of the respondents had already used the subcutaneous route for administration of drugs and 58% for hydration. Despite the team recognition of the potential for suffering of patients and the need for mitigation strategies, they remain linked to prognosis and not to symptomatic complexity. There are gaps in regard to control of pain, dyspnoea and in continuity of care.

Non-invasive ventilation in cardiogenic pulmonary edema in the emergency department.

Bilevel positive pressure (BiPAP) non-invasive ventilation (NIV) is frequently used in our emergency department (ED), as an adjuvant in the treatment of acute cardiogenic pulmonary edema (ACPE) to reduce the need for tracheal intubation (TI) in these patients. The purpose of our study was to evaluate the safety of NIV in patients with ACPE in our ED, used by a group of physicians outside the intensive care unit (ICU), by comparing our results with previously published results. We also wanted to identify possible additional advantages of NIV in the treatment of acpe. We recorded clinical and physiological data before and after NIV of all patients with diagnosis and treatment of ACPE in our ED and for whom NIV was ordered as adjuvant treatment, between July 2004 and February 28 2005. During this period, NIV was ordered in 17 patients with ACPE. The mean ventilation pressures used were p(INSP) 16.5 +/- 5 cm H2O and p(exp) 8.8 +/- 4 cm H2O. none of the patients refused NIV. In six patients NIV was not initiated immediately together with medical therapeutics. one patient required Ti and the other 16 (94%) improved after NIV. After the acpe episode had resolved, fourteen patients (82%) were eventually discharged from hospital whereas 3 (18%) died during hospitalization. We observed a statistically significant improvement after one hour of NIV in respiratory and pulse rate, arterial pH, PaCO2 and peripheral blood O2 saturation. Despite the small sample size, these results suggest that it is possible to use NIV in the treatment of ACPE outside the ICU, without increasing the risks of TI or decreasing efficacy. In these cases NIV probably accelerates clinical resolution and relieves symptoms.