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What's Buzzing in the Literature? Focusing on Palliative Care




Sean Marks, MD, and Melissa Atwood, DO

For many older adults living with chronic illness, palliative care often presents the most realistic and cost-effective way to reduce pain and improve quality of life. From diagnosis to end of life decisions, palliative care supports patients and their families in many dimensions of healthcare, including emotional and spiritual needs. Although many patients and providers view palliative care as a last resort approach to care in long-term care facilities and hospice care, the principles of palliative care are becoming increasingly more accepted across care settings. The current literature base reflects the evolving understanding of the role of palliation in healthcare. Sean Marks, MD, and Melissa Atwood, DO, specialize in palliative care; Marks is an associate professor of medicine, Medical College of Wisconsin, and Atwood is assistant professor, Children’s Hospital of Wisconsin-Main Campus. Annals of Long-Term Care: Clinical Care and Aging® asked Marks and Atwood to identify articles that they consider to be the most significant contributions to the palliative care literature within the past year. Their selections from the literature are given below, along with their rationale for including them.


A scenario-based, randomized trial of patient values and functional prognosis on intensivist intent to discuss withdrawing life support.

Authors: Turnbull AE, Krall JR, Ruhl AP, et al.

Published in: Crit Care Med. 2014;42(6):1455-1462.

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Why this article is important: As the population ages and medical technology advances, decisions about withdrawing life support from a patient who can no longer communicate may increase in frequency. All too often, patients have not made their end-of-life preferences known. Thus, clinicians commonly are forced to make shared decisions with patient surrogates who may be unclear of the patient’s wishes. This study explored factors that influenced intensivists’ intention to discuss withdrawal of life support in a hypothetical family meeting; 630 intensivists reviewed 10 clinical scenarios of a hypothetical patient with varying illness severity. They were randomly assigned to the control group or one of two experimental arms. In the control group, the family explained that the patient would not want continued life support without a reasonable chance of independent living. In the first experimental arm, the family conveyed that the patient would want life support regardless of functional outcome. In the second experimental arm, the values the family stated were the same as the control group but the intensivists were required to choose an estimated 3-month functional prognosis. The results showed that when clinicians were required to give a 3-month functional prognosis, surrogates were 49% more likely to discuss withdrawal of life support. Based on these results, clinicians may be more likely to have frank discussions with families about end-of-life care and make recommendations regarding withdrawal of life support when short-term functional prognosis is poor.


Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial.

Authors: Hatta K, Kishi Y, Wada K, et al; DELIRIA-J Group.

Published in: JAMA Psychiatry. 2014;71(4):397-403.

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Why this article is important: Delirium is an increasingly common and costly health issue affecting elderly inpatients. One randomized controlled trial and several case series have suggested that melatonin may be effective at preventing delirium in patients at risk. Ramelteon is a more potent and selective agonist for melatonin receptors; hence it may be an attractive pharmacotherapy for this clinical issue. In this randomized, rater-blinded placebo controlled multi-institution trial, researchers assessed the effectiveness of ramelteon in preventing delirium for at-risk patients. This study was not funded by a pharmaceutical company.

Inclusion criteria included an age of 65 to 89, recent hospital admission due to a serious medical problem, and an ability to take medications by mouth. The 33 patients randomized to ramelteon had a significantly lower risk of delirium (3% vs 32%). This is superior to what was found in a previous melatonin study—12% for melatonin vs 31% for placebo (Al-Aama T, Bryer C, Gutmanis, et al. Int J Geriatr Psychiatry.
2011;26[7]:687-694). The authors conclude that there is a possible pathologic role of melatonin neurotransmission in delirium and that ramelteon given nightly to elderly patients may provide protection against delirium. Further studies to confirm ramelteon’s effectiveness and better define which patients would most benefit from this medication would be needed.


Survival and functional outcomes after hip fracture among nursing home residents.

Authors: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM.

Published in: JAMA Intern Med. 2014;174(8):1273-1280.

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Why this article is important: It is well-known that hip fractures (HF) in the elderly cause significant morbidity and mortality. However, nursing home (NH) residents are often excluded from large-scale detailed analyses on HF and there is a paucity of details related to functional outcomes in this population. The authors’ goal was to evaluate and describe patterns and predictors of mortality and functional decline among NH residents after HF. Specifically they performed a retrospective analysis of 60,111 Medicare beneficiaries living in a NH who were hospitalized with a HF and evaluated patterns of survival and functional dependence in seven activities of daily living (ADLs) before and after fracture over a 4-year time frame.

They found that 36.2% of patients died within 180 days after HF and median survival was only 377 days. Even among the NH residents who were independent with ADLs at baseline, over half either died or were newly dependent in locomotion within 180 days. The factors most strongly associated with poor outcomes (both death and substantial within-resident changes in ADLs) were advanced age, non-operative management of HF, advanced comorbidities and severe cognitive impairment. This study highlights how NH patients are especially vulnerable after HF and underscores the importance of prevention of falls and the need for frank conversations with patients and family about possible outcomes and goals of care once HF occurs. The results of this study have prompted some experts to suggest that HFs in NH residents be a trigger for a palliative care screening assessment (Ko FC, Morrison RS. JAMA Intern Med. 2014;174[8]:1281-1282).

Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival.

Authors: Dermot Frengley J, Sansone GR, Shakya K, Kaner RJ.

Published in: J Am Geriatr Soc. 2014;62(1):1-9.

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Why this article is important: An estimated 3% to 7% of patients who survive on mechanical ventilation longer than 4 days require prolonged mechanical ventilation (PMV; ie, ventilation for >21 days). Most of these patients will leave the acute hospital setting and reside in a long-term acute care hospital (LTACH). Given that a great deal of resources are required to care for a patient in LTACH and that pulmonary function decreases with age, these investigators evaluated how age affects outcomes of patients requiring PMV. The study was a retrospective analysis over a 6-year time frame at a long-standing public LTACH in New York City with a diverse patient population and a well-known PMV active weaning program. The authors divided the elderly patients (N=540) into age-related subgroups: 65-69, 70-74, 75-79, 80-84, 85-89, and 90 and older. The primary outcome measures were weaning success, discharge disposition, and long-term survival.

As some readers may expect, patients were less likely to meet PMV weaning criteria and less likely to successfully wean from ventilation as age increased. However, factors other than age had a more significant impact on death. Specifically, pulmonary physiology measures and the number of medical comorbidities were stronger corollaries with long-term survival than age. Successful weaning was associated with a reduction in the risk of death by 62%. These findings offer great insight into the prognosis of patients who require PMV and should help guide providers and patients to more specific and nuanced predictors for long-term outcomes other than age. They also underline the importance of effective and standardized weaning protocols for this panel of patients.



Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer.

Authors: Obermeyer Z, Makar M, Abujaber S, Dominici F, Block S, Cutler DM.

Published: JAMA. 2014;312(18):1888-1896.

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Why this article is important: Challenges in promoting palliative and hospice care were identified in the 2014 Institute of Medicine report Dying in America. Even though the number of people receiving Medicare hospice benefit (MHB) has increased since the program’s inception, the MHB enrollment length has decreased while the end-of-life care intensity has increased. This study is the first to utilize exact matching pairs of Medicare data to methodically compare the healthcare utilization and costs for more than 18,000 patient pairs who differed in whether they were enrolled in hospice. The aim of this study is to determine whether the decrease in MHB hospice enrollment comes at the detriment of cost and healthcare utilization.

The results were rather compelling but likely not surprising. There was more than a 20% decrease in hospitalizations and intensive care admissions among the patients enrolled in hospice. Whereas more than 74% of the patients not enrolled in hospice died in either a hospital or nursing home; only 14% of the patients enrolled in hospice died in such a setting. Additionally there was almost a $9,000 cost difference in the last year of life among patients enrolled in hospice.

Although this study has been much referenced as a landmark in the field, the findings may raise more questions than they answer. Because these groups were not randomized, readers cannot tell if the cost and healthcare utilization differences were due to non-controlled factors other than hospice enrollment, such as differences in preferences for aggressive care between the two groups. Beyond that, does the decreased cost and more appropriate healthcare utilization translate into better quality care for the hospice patients? Considering recent research that has shown increasing rates of live discharges from hospice and that home hospice patients are not always visited by professional staff in the last days of life, this may be a valid question. Furthermore, not all cancer patients with a poor prognosis are willing to forgo curative treatments to enroll in hospice care, especially considering the advances with targeted and less toxic chemotherapies that are now available for many advanced cancers. For these reasons, it remains unclear how far and for which patients healthcare policy experts should be promoting hospice in cancer patients with a poor prognosis.


“Don’t get weak in your compassion”: bereaved next of kin’s suggestions for improving end-of-life care in Veterans Affairs Medical Centers.

Authors: Riggs JS, Woodby LL, Burgio KL, Bailey FA, Williams BR.

Published in: J Am Geriatr Soc. 2014;62(4):642-648.

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Why this article is important: Despite a preference to die at home, many Americans die within a hospital. Consequently, leaders within the Veterans Affairs (VA) Medical Centers (VAMCs) have been working to improve inpatient end-of-life care for veterans for over a decade. This qualitative study, involving semi-structured interviews with bereaved next of kin (NOK), is part of a larger VA research project: BEACON (Best Practices for End-of-Life Care for Our Nation’s Veterans) trial. Investigators assessed background information of the veteran, NOK’s perceptions around the time of the veteran’s death, and the NOK’s feelings about the care in general. The final question was “Do you have any suggestions for people at the VA that can make this experience any easier for other families?”

Through interactive negotiation and interpretation, the authors identified both positive and negative aspects of the end-of-life care rendered. Five major themes emerged above others as high priorities among the bereaved: compassionate care, good communication, support for family visits and privacy, need for death preparation and post-death guidance, and salience of relationship with the VA. When speaking about compassion, one NOK remarked how he hopes that providers who “see death after death...don’t get weak in your compassion toward people.”

Although there are limitations to the methodology, this study offers salient feedback from the people who are likely best suited to define good end-of-life care—the bereaved. Hence, providers and leadership should be aware of these findings and develop strategies to prevent compassion fatigue among clinicians while fostering end-of-life communication skills through education and practice. Lastly, the feedback garnered from this study should heighten the importance to improve practical matters, such as the end-of-life care environment and bereavement care.

Identifying barriers to pain management in long-term care.

Authors: Egan M, Cornally N.

Published in: Nurs Older People. 2013;25(7):25-31.

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Why this article is important: Chronic pain affects an estimated 45% to 80% of the elderly in long-term care (LTC). Untreated pain can lead to undue suffering and agitation in the elderly. The goal of the study was to identify three main barriers to optimal pain management in LTC from a nursing perspective: caregiver-related, patient-related, and organizational-related. The study utilized a quantitative, cross-sectional, descriptive design and data was collected from nurses at two private and three public local LTC facilities in Ireland (N=83). A self-report questionnaire was used and all questions relating to barriers were multiple choice. Possible responses varied from “never interferes” to “always interferes” and each possible response had a numerical value which corresponded to a seven-point Likert scale.

Patient-related barriers were rated as having the greatest impact on optimal pain management. “Difficulty assessing pain in older people due to problems with cognition (delirium, dementia),” was the highest barrier in this category, followed by “older patients’ difficulty with completing pain scales.” Organizational-related barriers were rated as the second most important category overall, and the leading reason was “lack of opportunity to discuss an older patient’s pain management directly with palliative care team.” Another critical barrier in this group was “inadequate time for health teaching with older patients.” Lastly, caregiver-related barriers were rated lowest in importance. The variable that nurses perceived as interfering most often was “antipsychotics are considered before pain medications in agitated patients.” The second greatest barrier was “physicians’ reluctance to prescribe adequate pain relief in older patients for fear of overmedicating those with dementia or delirium.” This study illustrates that nurses appreciate a wide variety of barriers for optimal pain control for residents in LTC. Consideration of specialist teams in the management of chronic pain, perhaps in the form of pain champions who could educate others at the facility, may greatly benefit the care of elderly residents in LTC facilities.

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