Palliative care, COVID-19, and the suffering quotient.

OBJECTIVES: The COVID-19 pandemic presented many challenges for patients with palliative care needs and their care providers. During the early days of the pandemic, visitors were restricted on our palliative care units. These restrictions separated patients from their families and caregivers and led to considerable suffering for patients, families, and health-care providers. Using clinical vignettes that illustrate the suffering caused by visiting restrictions during the pandemic, the introduction of a new concept to help predict when health-care providers might be moved to advocate for their patients is introduced. METHODS: We report 3 cases of patients admitted to a palliative care unit during the COVID-19 pandemic and discuss the visiting restrictions placed on their families. In reviewing the cases, we coined a new concept, the "Suffering Quotient" (SQ), to help understand why clinical staff might be motivated to advocate for an exemption to the visiting restrictions in one situation and not another. RESULTS: This paper uses 3 cases to illustrate a new concept that we have coined the Suffering Quotient. The Suffering Quotient (SQ) = Perceived Individual (or small group) Suffering/Perceived Population Suffering. This paper also explores factors that influence perceived individual suffering (the numerator) and perceived population suffering (the denominator) from the perspective of the health-care provider. SIGNIFICANCE OF RESULTS: The SQ provides a means of weighing perceived patient and family suffering against perceived contextual population suffering. It reflects the threshold beyond which health-care providers, or other outside observers, are moved to advocate for the patient and ultimately how far they might be prepared to go. The SQ offers a potential means of predicting observer responses when they are exposed to multiple suffering scenarios, such as those that occurred during the COVID-19 pandemic.

Alternatives to Hospitalization: Adding the Patient Voice to Advanced Heart Failure Management.

Advanced heart failure (HF) is associated with the extensive use of acute care services, especially at the end of life, often in stark contrast to the wishes of most HF patients to remain at home for as long as possible. The current Canadian model of hospital-centric care is not only inconsistent with patient goals, but also unsustainable in the setting of the current hospital-bed availability crisis across the country. Given this context, we present a narrative to discuss factors necessary for the avoidance of hospitalization in advanced HF patients. First, patients eligible for alternatives to hospitalization should be identified through comprehensive, values-based, goals-of-care discussions, including involvement of both patients and caregivers, and assessment of caregiver burnout. Second, we present pharmaceutical interventions that have shown promise in reducing HF hospitalizations. Such interventions include strategies to combat diuretic resistance, as well as nondiuretic treatments of dyspnea, and the continuation of guideline-directed medical therapies. Finally, to successfully care for advanced HF patients at home, care models, such as transitional care, telehealth, collaborative home-based palliative care programs, and home hospitals, must be robust. Care must be individualized and coordinated through an integrated care model, such as the spoke-hub-and-node model. Although barriers exist to the implementation of these models and strategies, they should not prevent clinicians from striving to provide individualized person-centred care. Doing so will not only alleviate strain on the healthcare system, but also prioritize patient goals, which is of the utmost importance.

L'insuffisance cardiaque avancée est associée à une utilisation considérable des services de soins de courte durée, surtout en fin de vie et souvent en contradiction totale avec les désirs de la plupart des patients, qui sont de rester à la maison le plus longtemps possible. Le modèle canadien actuel, centré sur les soins hospitaliers, n'est pas seulement incompatible avec les objectifs des patients, mais il est n'est pas viable vu le manque criant de lits constaté dans des hôpitaux de partout au pays. En tenant compte de ce contexte, nous présentons une perspective permettant de discuter des facteurs nécessaires pour éviter l'hospitalisation des patients atteints d'insuffisance cardiaque avancée. Il faut d'abord identifier les patients admissibles à des soins non hospitaliers en menant des discussions exhaustives sur les objectifs de soins qui se fondent sur les valeurs et qui portent notamment sur la participation du patient et de ses aidants et sur l'évaluation de l'épuisement des aidants. Nous présentons ici les interventions pharmaceutiques qui se sont révélées prometteuses dans la réduction des hospitalisations pour cause d'insuffisance cardiaque. Il s'agit de stratégies visant à lutter contre la résistance aux diurétiques et de traitements non diurétiques de la dyspnée, ainsi que de la poursuite des traitements médicaux indiqués par les lignes directrices. Enfin, pour bien soigner les patients atteints d'insuffisance cardiaque avancée à domicile, les modèles de soins, comme les soins de transition, la télémédecine, les programmes collaboratifs de soins palliatifs à domicile et les programmes d'hospitalisation à domicile, doivent être robustes. Les soins doivent être personnalisés et coordonnés par un modèle de soins intégré, comme le modèle en étoile (spoke-hub-and-node). Bien qu'il existe des obstacles à l'instauration de ces modèles et stratégies, ceux-ci ne devraient pas empêcher les médecins de s'employer à offrir des soins adaptés axés sur la personne. Cette pratique libérera le système de santé d'un poids et permettra de mettre de l'avant les objectifs des patients, qui sont de la plus grande importance.

Delivery of End-of-Life Care in Patients Requesting Withdrawal of a Left Ventricular Assist Device Using Intranasal Opioids and Benzodiazepines.

With the increasing prevalence of the left ventricular assist device (LVAD) in patients with end-stage cardiomyopathies, an increasing number of these patients are dying of noncardiac conditions. It is likely that the palliative care clinician will have an ever-increasing role in managing end of life for patients with LVADs, including discontinuation of LVAD support. There exists a paucity of literature describing strategies for effective delivery of palliative care in patients requesting discontinuation of LVAD therapy. Here, we present a case of a patient with metastatic cancer who requested LVAD discontinuation. Because of practical concerns and patient preference, the patient did not have intravenous (IV) access and medications requiring IV administration could not be used. Therefore, a strategy using intranasal midazolam and sufentanil was applied, the LVAD was deactivated, and the patient died comfortably. This case is, to our knowledge, the first to describe a strategy for delivery of palliative care in patients requesting discontinuation of LVAD support, particularly in the absence of IV access. Such a strategy may be applicable to patients wishing to die at home, and therefore allow greater latitude for patients and clinicians in their approach to the end of life.

The Use of Intranasal Fentanyl for the Palliation of Incident Dyspnea in Advanced Congestive Heart Failure: A Pilot Study.

BACKGROUND:: Dyspnea is distressing in palliative patients with end-stage heart failure and many are hospitalized to optimize this symptom. We hoped to conduct a pilot study to determine whether the administration of intranasal fentanyl would decrease activity-induced dyspnea in this patient population. METHODS:: Patients performed two 6-minute walk tests with and without the administration of 50 µg of intranasal fentanyl. Vital signs were recorded before and after each walk, as were participant reported dyspnea and adverse events scores. RESULTS:: Twenty-four patients were screened, 13 were deemed eligible, and 6 completed the study. Dyspnea scores changed from a mean of 6.00 immediately after the walk without fentanyl to a mean of 3.83 after the walk with fentanyl ( P = .048). Mean respiratory rate decreased from 21.0 to 18.7 ( P = .034) breaths per minute and was considered a favorable outcome by the participants. Distance walked did not significantly increase with the fentanyl pretreatment (136.0-144.2 m; P = .283), although the participants reported feeling better while walking a similar distance. CONCLUSIONS:: In this pilot study, the preadministration of intranasal fentanyl prior to activity in palliative, end-stage hospitalized heart failure patients, safely reduced tachypnea, and the feeling of shortness of breath. This approach may help palliate advanced heart failure patients by alleviating symptoms brought on by exertional activities.

Palliative Medicine-Becoming a Subspecialty of the Royal College of Physicians and Surgeons of Canada.

The discipline of palliative medicine in Canada started in 1975 with the coining of the term "palliative care." Shortly thereafter, the provision of clinical palliative medicine services started, although the education of the discipline lagged behind. In 1993, the Canadian Society of Palliative Care Physicians (CSPCP) started to explore the option of creating an accredited training program in palliative medicine. This article outlines the process by which, over the course of 20 years, palliative medicine training in Canada went from a mission statement of the CSPCP, to a 1 year of added competence jointly accredited by both the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada, to a 2-year subspecialty of the Royal College with access from multiple entry routes and a formalized accrediting examination.

Does gynecologic malignancy predict likelihood of a tertiary palliative care unit hospital admission? A comparison of local, provincial and national death rates.

OBJECTIVE: The purpose of this study was to determine whether the presence of gynecologic malignancies predicts the likelihood of a tertiary palliative care unit hospital admission. METHOD: In this study, patients admitted to a specialized tertiary palliative care unit (TPCU) with gynecologic malignancies were compared to national and provincial death rates to determine if gynecologic malignancy predicts admission, and subsequent death, in a TPCU. RESULTS: Eighty-two gynecologic cancer patients were admitted to our TPCU over the 5- year study period. Out of all cancer deaths in the TPCU, death from ovarian cancer was 3.7% compared with 2.4% (p = 0.0068) of all cancer deaths in Manitoba and 2.3% (p = 0.0043) of all cancer deaths in Canada. Cervical cancer accounted for 1.7% of all our patients deaths compared with 0.7% (p = 0.0001) provincially and 0.6% (p = 0.0001) nationally. Uterine cancer deaths were not significantly different from the provincial and national death rates, whereas vulvar and fallopian cancers were too rare to allow for statistical analysis. SIGNIFICANCE OF RESULTS: Gynecologic cancers may be predictive of admission to a palliative care unit.

Corticosteroid-induced diabetes in palliative care.

BACKGROUND: Corticosteroids are one of the most commonly used medications in palliative care. Although the benefit of corticosteroids generally outweighs the risk in the palliative population, side effects are common and necessitate careful consideration prior to prescribing. In March of 2010, a guideline for monitoring blood glucose values was implemented as part of our standard care within our two inpatient tertiary palliative care units. METHOD: A retrospective study was conducted, the aim of which was twofold. First, we hoped to determine a prevalence rate for steroid-induced diabetes mellitus (SDM) in palliative care and whether or not screening glucose levels twice weekly was appropriate or required. Second, we wanted to determine if possible predictors existed for the development of SDM in a palliative population, thereby identifying the patients most at risk who would benefit from ongoing glucose monitoring. RESULTS AND DISCUSSION: We found that SDM is more common in palliative care patients than previously thought. Our study showed a higher likelihood of developing hyperglycaemia with higher doses of dexamethasone. But although dose is correlated with hyperglycemia, patients without high doses were also at risk. Further study is currently underway with slight modifications to the guideline to more accurately assess the physical burden, as well as the emotional and financial cost of a hyperglycemia screening protocol.