Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care.

Objectives: Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients. Material and methods: A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft. Results: The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors. Conclusion: The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

Effects of Immersive Virtual Reality on Patient Anxiety During Surgery Under Regional Anesthesia: A Randomized Clinical Trial.

Background: Surgery and anesthesia are associated with increased patient anxiety. Perioperative anxiety is a common problem in regional anesthesia procedures and has an extensive impact. Immersive virtual reality (IVR) is a potential non-pharmacological distraction method to reduce anxiety. Immersive virtual reality creates a virtual environment that allows patients to interact and immerse in the virtual world, reducing patient anxiety. Objectives: This study aimed to examine the effect of IVR on the anxiety of patients undergoing regional anesthetic surgery. Methods: A total of 30 participants referred to Dr. Kariadi General Hospital (Indonesia) from October 2021 to December 2021 were enrolled in this randomized, single-blind clinical trial. The patients were divided into virtual reality (VR) and control groups (n = 15 in each group). The control group received midazolam (0.02 mg/kg) as premedication. The VR group received an IVR intervention without premedication. The data of anxiety scores were assessed using the Spielberger State-Trait Anxiety Inventory 6 (STAI-6). This study also collected vital signs, side effects, and patient and surgeon satisfaction level data. Results: The average anxiety level during surgery in the operating room decreased in both groups (P < 0.05); the VR group had a lower score (P = 0.04). A significant reduction in perioperative anxiety levels was observed in the VR group compared to the control group. The patient satisfaction level was also significantly higher in the VR group than in the control group (P = 0.024). Both groups had no significant difference in monitored vital signs, side effects, and surgeon satisfaction. Conclusions: The IVR intervention could reduce anxiety in patients undergoing surgery under regional anesthesia and improve patient satisfaction.

Perioperative Factors Impact on Mortality and Survival Rate of Geriatric Patients Undergoing Surgery in the COVID-19 Pandemic: A Prospective Cohort Study in Indonesia.

Background: The COVID-19 pandemic continues to have an impact on geriatric patients worldwide since geriatrics itself is an age group with a high risk due to declined physiological function and many comorbidities, especially for those who undergo surgery. In this study, we determine the association between perioperative factors with 30-day mortality and a survival rate of geriatric patients undergoing surgery during COVID-19 pandemic. Methods: A prospective cohort study was conducted at 14 central hospitals in Indonesia. The recorded variables were perioperative factors, 30-day mortality, and survival rate. Analyses of associations between variables and 30-day mortality were performed using univariate/multivariable logistic regression, and survival rates were determined with Kaplan−Meier survival analysis. Results: We analyzed 1621 elderly patients. The total number of patients who survived within 30 days of observation was 4.3%. Several perioperative factors were associated with 30-day mortality (p < 0.05) is COVID-19 (OR, 4.34; 95% CI, 1.04−18.07; p = 0.04), CCI > 3 ( odds ratio [OR], 2.33; 95% confidence interval [CI], 1.03−5.26; p = 0.04), emergency surgery (OR, 3.70; 95% CI, 1.96−7.00; p ≤ 0.01), postoperative ICU care (OR, 2.70; 95% CI, 1.32−5.53; p = 0.01), and adverse events (AEs) in the ICU (OR, 3.43; 95% CI, 1.32−8.96; p = 0.01). Aligned with these findings, COVID-19, CCI > 3, and comorbidities have a log-rank p < 0.05. The six comorbidities that have log-rank p < 0.05 are moderate-to-severe renal disease (log-rank p ≤ 0.01), cerebrovascular disease (log-rank p ≤ 0.01), diabetes with chronic complications (log-rank p = 0.03), metastatic solid tumor (log-rank p = 0.02), dementia (log-rank p ≤ 0.01), and rheumatology disease (log-rank p = 0.03). Conclusions: Having at least one of these conditions, such as COVID-19, comorbidities, emergency surgery, postoperative ICU care, or an AE in the ICU were associated with increased mortality in geriatric patients undergoing surgery during the COVID-19 pandemic.

Comorbidities and COVID-19 status influence the survival rate of geriatric patients in intensive care units: a prospective cohort study from the Indonesian Society of Anaesthesiology and Intensive Therapy.

BACKGROUND: With the more advanced science in the field of medicine and disease management, the population of geriatric intensive care patients is increasing. The COVID-19 pandemic has impacted healthcare management around the globe, especially on critically-ill elderly patients. We aim to analyse the relationship between underlying illnesses, including COVID-19, and the survival rate of elderly patients who are treated in the intensive care setting. METHODS: We conducted a prospective cohort study at 14 teaching hospitals for Anaesthesiology and Intensive Therapy Education in Indonesia. We selected all subjects with 60 years of age or older in the period between February to May 2021. Variables recorded included subject characteristics, comorbidities, and COVID-19 status. Subjects were followed for 30-day mortality as an outcome. We analysed the data using Kaplan-Meier survival analysis. RESULTS: We recruited 982 elderly patients, and 728 subjects were in the final analysis (60.7% male; 68.0 ± 6.6 years old). The 30-day mortality was 38.6%. The top five comorbidities are hypertension (21.1%), diabetes (16.2%), moderate or severe renal disease (10.6%), congestive heart failure (9.2%), and cerebrovascular disease (9.1%). Subjects with Charlson's Comorbidity Index Score > 5 experienced 66% death. Subjects with COVID-19 who died were 57.4%. Subjects with comorbidities and COVID-19 had lower survival time than subjects without those conditions (p < 0.005). Based on linear correlation analysis, the more comorbidities the geriatric patients in the ICU had, the higher chance of mortality in 30 days (p < 0.005, R coefficient 0.22). CONCLUSION: Approximately one in four elderly intensive care patients die, and the number is increasing with comorbidities and COVID-19 status.

An Association Between C-Reactive Protein Levels and the Occurrence of Cognitive Dysfunction After Heart Valve Replacement.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is defined as cognitive dysfunction related to inflammation after surgical procedures, which is common following cardiac surgery. Cognitive deficits are thought to result from a systemic inflammatory response. C-reactive protein (CRP) and other proinflammatory cytokines, which are released in response to inflammation, disrupt the blood-brain barrier and neurotransmission, resulting in POCD. This study aimed to determine the correlation between POCD and increased levels of CRP in patients who had undergone heart valve replacement. METHODS: This study comprised 32 patients with normal cognitive function undergoing heart valve replacement. The CRP levels were measured before surgery and on the second postoperative day, and cognitive function was examined via the Indonesian-adapted Montreal Cognitive Assessment (MOCA-INA) on the third postoperative day. Data were analyzed using Spearman correlation test. RESULTS: Of the 32 patients, 28 (87.5%) experienced POCD. The median level of CRP was 6.6 mg/dL (interquartile range: 4.0, 8.3 g/dL). According to Spearman correlation test, increased levels of CRP were significantly related to POCD following heart valve replacement (p = 0.003, r = 0.501). The receiver operating characteristic curve indicated that the CRP cutoff level was 3.345 mg/dL, and the sensitivity and specificity were 89.3% and 75%, respectively. CONCLUSION: High expression level of CRP was correlated with POCD following heart valve replacement.

A Review of Biographical Work in Palliative Care.

AIM: We find several interventions in palliative care to cover psychosocial needs and to relieve distress of patients. There is a growing interest in therapies using biographical approaches, but discussion about interventions is sparse, and there is no concept for comprehensive and sustainable provision. Research on interventions with a single biographical approach is available, but there is no systematic review that tests a range of interventions. Therefore, we look at all studies using biographical approaches for patients and/or caregivers. METHODS: In May 2017, the electronic databases of Medline, PubMed, EMBASE, Central, and PsycINFO were searched for qualitative and quantitative empirical reports. Interventions for patients, dyads of patient and caregiver, and bereaved caregivers were included. Data analysis follows the guideline PRISMA. RESULTS: Twenty-seven studies were included - 12 using a quantitative evaluation and 15 using a qualitative evaluation. Interventions using biographical approach are widespread and show broad variations in comprehension and performance. The scope of interest lays on patient and family in trajectory of illness and bereavement. The most common interventions used were life review, short life review, dignity therapy, and bereaved life review. Biographical approaches increase quality of life and spiritual well-being and reduce depression. Interventions show effects independently of the number of sessions or provider. CONCLUSIONS: Transferability of concepts seems limited due to the implications of culture on themes emerging in interventions. In some case, there were predicting factors for responders and nonresponders. Further research is needed.