Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.

All healthcare services strive to achieve the six factors of quality health care - safe, effective, patient-centered, timely, efficient and equitable. Yet multiple structural, process, policy and people factors can combine to result in medical error and patient harm. Measuring the quality of palliative care has many challenges due to its presence across multiple health sectors, variable skill and experience of providers and lack of defined processes for providing services. In Canada there is screening for symptoms and distress in most cancer centers, but not in non-cancer diseases. Screening for distress and disease burden can identify suffering, that when properly addressed, improves quality of life and reduces depression and hopelessness that can lead to requests for hastened death. Our hypothesis is that some requests for hastened death (known as Medical Assistance in Dying or MAiD in Canada) are driven by lack of access to palliative care or lack of quality in the palliative care attempting to address disease burden and distress such that the resulting provision of hastened death is a medical error. The root cause of the error is in the lack of quality palliative care in the previous weeks, months and years of the disease trajectory - a known therapy that the system fails to provide. The evidence for palliative care addressing symptoms and improving quality of life and mood as well as providing caregiver support is established. Early evidence supporting the use of psychotherapeutics in emotional and existential distress is also considered. We present three cases of request for assisted death that could be considered medical error. The paper references preliminary evidence from a review of previous access to palliative care in a limited number of MAiD cases showing that only a minority were identified as having palliative care needs prior to the admission where MAiD was provided. The evidence linking disease burden to hopelessness, depression and hastened death is provided. The many studies revealing the inequity or underservicing of the Canadian population with regards to palliative care are reviewed. We examine a recent framework for palliative care in Canada and point out the need for more aggressive use of standards, process and policies to ensure that Canadians are receiving quality palliative care and that it is equitably accessible to all.

Neuropsychiatric symptoms of dementia: consent, quality of life, and dignity.

Degenerative forms of dementia are progressive, incurable, fatal, and likely to cause suffering in conjunction with personal incapacity. Timely diagnostic disclosure and counseling can facilitate important advance care planning. The risk of harm associated with neuropsychiatric symptoms (NPS) of dementia often has to be balanced against the risk of harm associated with medication management of NPS. A palliative care framework can help preserve autonomy, quality of life, comfort, and dignity for patients with NPS.

Behavioral and psychological symptoms in moderate to severe Alzheimer's disease: a palliative care approach emphasizing recognition of personhood and preservation of dignity.

The assessment and management of behavioral and psychological symptoms of dementia (BPSD) in moderate to severe Alzheimer's disease (AD) can be challenging, and ethical dilemmas often arise. Clinicians often perceive a disconnect between evidence-based guidelines and the challenges of treating BPSD in moderate to severe AD. Reconciliation of salient ethical issues can help bridge this disconnect. In view of the fact that AD is a progressive and ultimately fatal disease, and given that there are often competing considerations when managing BPSD in moderate to severe AD, we propose a palliative care approach that prioritizes the recognition of personhood and the preservation of dignity. We present case illustrations, discuss the concepts of dignity and personhood during palliative care in AD, and encourage the use of the bioethical grid in navigating complex clinical challenges.

Sublingual sufentanil for incident pain and dementia-related response agitation.

Patients with moderate to severe dementia commonly exhibit agitation and aggression in response to personal care. Incident pain is a common factor underlying response agitation that in turn can obstruct the delivery of essential nursing care. Medications commonly used to manage response agitation have specific risks in patients with dementia. This report details the case of a patient suffering from severe dementia with incident pain and response agitation that remitted with the use of sublingual sufentanil, a rapid-onset and ultra-brief acting opioid analgesic.

Alternatives to atypical antipsychotics for the management of dementia-related agitation.

Numerous recent studies have challenged the widely held belief that atypical antipsychotics are safe and effective options for the treatment of behavioural problems such as agitation in patients with dementia. Accordingly, there is a need to reconsider the place of atypical antipsychotics in the treatment of patients with dementia. The present article is intended to assist clinicians with the assessment and pharmacological management of agitation in patients with dementia. We review the risk-benefit evidence for the use of atypical antipsychotics in patients with dementia-related agitation (DRA). Emerging evidence indicates that, for patients with dementia, the risks associated with atypical antipsychotics may outweigh the benefits except for patients with severe agitation who require short-term chemical restraint. We then discuss the importance of a careful assessment to rule out potentially reversible factors contributing to DRA. Finally, we summarize the evidence supporting the use of medications other than antipsychotics to treat DRA. There is wide variability in the levels of evidence supporting the use of non-antipsychotic medication for the treatment of DRA. The best evidence currently exists for cholinesterase inhibitors and serotonin-specific reuptake inhibitor antidepressants. Emerging reports suggest that numerous other medications, for example, antiepileptics, lithium, anxiolytics, analgesics, beta-adrenoceptor antagonists, cannabinoid receptor agonists and hormonal agents, may prove to be viable alternatives to antipsychotics for the treatment of severe DRA and more research is urgently needed to help assess the effectiveness of these agents. A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage DRA.

Differentiating the dementias. Revisiting synucleinopathies and tauopathies.

Dementia is a common, chronic and progressive illness. Many different types of dementia exist. It is important to have knowledge of the various dementia presentations so that the clinician can differentiate one type from another. Past and current approaches of classifying dementias are reviewed in this paper. The past cortical/subcortical scheme is reviewed as well as the current synucleinopathy/tauopathy scheme. This paper focuses on the most common synucleinopathies and tauopathies including Alzheimer's Dementia, Dementia with Lewy Bodies, Parkinson's Disease, Frontotemporal Dementia, Progressive Supranuclear Palsy, Multiple System Atrophy and Corticobasal Ganglionic Degeneration. We systematically approach each dementia and review cognitive, psychiatry and neurological features of each. We also compare and contrast each dementia and the synucleinopathies and taupoathies alike. Our goal is to provide the clinician with sufficient knowledge to competently and confidently diagnose a patient who presents with progressive cognitive decline and deterioration in functioning.

Disconnection of language and memory in semantic dementia: a comparative and theoretical analysis.

In this paper, we present an illustrative case of Semantic Dementia (SD) and we review the literature on this relatively rare progressive neurodegenerative disorder. After reviewing the clinical, neuroimaging, neuropathological, and genetic features of SD, we propose a theoretical framework that addresses features of SD and relates them to features of other well known neuropsychiatric syndromes. Our 'on-line / off-line disconnection' model seeks to conceptualize SD as a syndrome of disconnection between two large distributed cortical networks, namely, between those networks that subserve language function and those that subserve memory function.

Successful ECT in a patient with an orbital cavernous hemangioma.

There are no cases in the literature describing the use of electroconvulsive therapy (ECT) in a patient with an intraorbital vascular mass. We report the clinical course of a 69-year-old female with a cavernous hemangioma of the left orbit who was successfully treated with ECT for major depressive disorder. There were no apparent effects on the orbital hemangioma as a result of ECT-related blood pressure elevations measured up to 195/90 mm Hg despite pretreatment with intravenous esmolol. Modulation of ECT-related cardiovascular changes in the presence of intracranial or intraorbital vascular masses remains advisable to reduce the risk of an adverse vascular event during ECT. The use of propofol anesthesia appears to be preferable in such cases.

Phenotypic spectra of bipolar disorder in responders to lithium versus lamotrigine.

OBJECTIVE: We conducted a study of clinical presentation and family history in patients responsive to either of two commonly used mood stabilizers, lithium and lamotrigine. METHODS: The sample included 164 subjects from 21 families of bipolar probands, 14 responders to lithium and seven to lamotrigine. Diagnostic information on first-degree relatives was obtained in a blind fashion through a combination of direct interviews (SADS-L) and family history assessments (FH-RDC). RESULTS: The probands differed with respect to clinical course (episodic in the lithium group, rapid cycling in the lamotrigine group), and comorbidity (panic attacks and substance abuse in the lamotrigine group). The relatives of lithium responders had significantly higher risk of bipolar disorder while relatives of lamotrigine responders had higher prevalence of schizoaffective disorder, major depression and panic attacks. CONCLUSIONS: These findings suggest that lithium- and lamotrigine-responsive patients differ with respect to course of illness, comorbidity and family history and may represent distinct subtypes of bipolar disorder.