Antithrombotic Therapy: Evaluation of the Safety of Performing Core Needle Biopsy of the Breast Without Suspending Medication
.

BACKGROUND: Patients are increasingly presenting for outpatient breast biopsy while taking medically necessary antithrombotic therapy. Cessation of this medication prior to biopsy increases patients' risk of vascular complications. 
. OBJECTIVES: This article evaluates the safety of performing core needle biopsies of the breast in patients without suspending prescription antithrombotic therapy. 
. METHODS: In this retrospective chart review study, patients continued prescription antithrombotic therapy prior to and including the day of biopsy. Follow-up telephone assessment, relying on patient self-report, was completed on the same or next business day. The chart review included report of bleeding as a postprocedure complication.
. FINDINGS: None of the 42 women who completed core needle biopsy of the breast while on antithrombotic therapy reported postdischarge bleeding, and 2 reported hematoma, supporting the safety of continuing antithrombotic therapy in patients who undergo core needle biopsy of the breast.

Families speak about inpatient end-of-life care.

Death is an emotional event that leaves lasting memories for the bereaved. This article describes the qualitative analysis of a mailed family survey addressing experiences with community hospital inpatient end-of-life care. Family members identified and appreciated symptom management and caring behaviors such as compassion and communication; they also noted the absence of these caring behaviors. Effective application of these behaviors to the dying experience should improve family satisfaction with end-of-life care.

Family-driven quality improvement in inpatient end-of-life care.

To enhance end-of-life care in a community hospital system, an interdisciplinary team designed and implemented a mail survey to obtain feedback from families of inpatients who died. The 855 completed surveys (a 31% response rate) demonstrate that bereaved families are willing to give feedback on care received from nurses and physicians and attention paid to the personal needs of patients and families. The team used families' feedback to shape quality improvement initiatives and focused on questions with comparatively lower scores: physician communication, physician compassion, and family understanding of what to expect as their loved one approached the end of life.

Evaluation of a Comprehensive, Adaptable, Life- Affirming, Longitudinal (CALL) palliative care project.

BACKGROUND: Many persons with life-threatening illnesses require services before they begin receiving hospice or hospital-based palliative care. Although health care professionals focus on diagnosis, treatment, and comfort care, patients and families view the illness as it impacts their whole life. OBJECTIVE: Evaluating a Comprehensive, Adaptable, Life-Affirming, Longitudinal (CALL) intervention to patients with life-threatening cancer, cardiac illness, respiratory conditions or dementia. The CALL Care interventions are consistent with the 2004 Clinical Practice Guidelines for Quality Palliative Care. DESIGN: Prospective observational study. SETTING AND SUBJECTS: Eleven sites (1 primary care, 8 acute care, and 2 long term care) located around the United States. Two hundred ninety-five patients and families enrolled in the study; many were enrolled for over 12 months. MEASUREMENTS: Patient self-reported Modified City of Hope Questionnaire addressing physical, psychosocial, emotional, and spiritual status and health care experiences; completed at enrollment and every three months. Family members completed Modified City of Hope Bereaved Family Questionnaire, with contents similar to the patient questionnaire. Sites compiled health care and community services utilization data regularly. RESULTS: Participants reported improved pain and symptom management. Fewer than one third were hospitalized (29%), and 7% had a critical care admission while enrolled. In addition, participants had high use of hospice (48% of those who died), and were likely to die at home (38% of those who died). CONCLUSIONS: CALL Care is an effective interdisciplinary intervention approach to individualize care for people living with life-threatening illness.

A "CALL" for community-focused palliative care.

Providing interdisciplinary coordinated health and social services has a profound positive impact on patients and families facing life-threatening illness. CALL Care is a demonstration project designed to provide this type of care and bridge gaps in the existing palliative care system. The program seeks to provide care that is comprehensive, adaptable, life-affirming, and longitudinal. Hallmarks of the approach include identification and offer of assistance to those facing terminal illness as close to diagnosis as possible, periodic comprehensive assessments of the patient and family situation, coordination of health and social care services made possible by an active interdisciplinary team process with a single care coordinator, and links to community resources. This article describes the CALL Care experience, presents several case studies illustrative of the interventions and their impact, and provides recommendations for those seeking to make a similar commitment to integrated palliative care services.

Outcomes of pain in frail older adults with dementia.

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.