Polypharmacy in Patients With Advanced Cancer and Pain. A European Cross-Sectional Study of 2282 Patients

• Aleksandra Kotlinska-Lemieszek, MD, PhD
,
• Ørnulf Paulsen, MD Stein Kaasa, MD, PhD Pål Klepstad, MD, PhD

Received 20 October 2013; received in revised form 24 February 2014; accepted 2 April 2014. published online 28 April 2014.

Abstract 

Context

Patients with advanced cancer need multiple drugs to control symptoms and to treat cancer and concomitant diseases. At the same time, the goal of treatment changes as life expectancy becomes limited. This results in a risk for polypharmacy, maintained use of unneeded drugs, and drug-drug interactions (DDIs).

Objectives

The aim of the study was to analyze the use of medications, and to identify unneeded drugs as well as drugs and drug combinations with a risk for DDIs in a cohort of advanced cancer pain patients, defined by a need for a World Health Organization (WHO) analgesic ladder step III opioid.

Methods

All drugs taken within a study day by cancer patients receiving opioids for moderate or severe pain (step III opioids) were analyzed. Non-opioids and adjuvants were analyzed for their use across countries. Unneeded medications as well as drugs and drug combinations with a risk for pharmacodynamic and pharmacokinetic DDIs were identified on the basis of published literature and electronic resources.

Results

In total, 2282 patients from 17 centers in 11 European countries were included. They received a mean of 7.8 drugs (range 1-20). Over one-quarter used 10 or more medications. The drugs and drug classes most frequently co-administered with opioids were: proton pump inhibitors, laxatives, corticosteroids, paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, metoclopramide, benzodiazepines, anticoagulants, antibiotics, anticonvulsants, diuretics and antidepressants. The use of non-opioids and essential adjuvants varied across countries. Forty-five percent of patients received unnecessary or potentially unnecessary drugs and about 7% were given duplicate or antagonizing agents. Exposures to DDIs were frequent and increased the risk of sedation, gastric ulcerations, bleedings, and neuropsychiatric and cardiac complications. Many patients were exposed to pharmacokinetic DDIs involving CYP450, including 58% who used a step III opioid CYP3A4 substrate, and more than 10% who were given major CYP3A4 inhibitors or inducers.

Conclusion

Patients with cancer treated with a WHO step III opioid use a high number of drugs. Non-opioid analgesics and corticosteroids are frequently used, but different patterns of use between countries were found. Many patients receive unneeded drugs and are at risk of serious DDIs. These findings demonstrate that drug therapy in these patients need to be evaluated continuously.

Key Words: pharmacotherapy, polypharmacy, cancer pain, palliative care, opioids, non-opioids, coanalgesics, adjuvants, unneeded drugs, unnecessary drugs, drug-drug interactions

من يدحرج الحجر عن باب كل قلب؟

في إنجيل اليوم الأحد الثاني بعد الفصح المعروف ايضًا بأحد حاملات الطيب كان تساؤل النسوة في طريقهن الى القبر: "من يدحرج لنا الحجر عن باب القبر؟". كان الجواب من السماء انه قد قام وليس هو ههنا. عمن تبحثنَ؟ يسوع الناصري اطلبنه في السماء.

 ظهر المسيح غالبا وهو حيّ الى الأبد بعد ان انطلق من مملكة الموت الى ملكوت الحياة وساد الأزمنة كلها، كل ما كان منها وما سيأتي، وعاد الى الآب حيث يهيمن على الكون كله. ولكننا لا نعي هذا. عند الكثرة من المسيحيين انه قد جاء وانه قد غاب. يرتّبون حياتهم او لا يرتّبونها. مقاطع صغيرة من الإنجيل يذكرونها هنا وهناك حسب ممارسات هزيلة يقومون بها. ولكن لا يبدو ان يسوع المسيح مسيطر على قلوب أتباعه او من ظنوا انهم أتباعه. أغنية غنوها خلال موسم الفصح وذهبت.

لو كنا واعين حقا أن المسيح قد قام فلا يمكننا ان نتصرف كما نتصرف اليوم، ولكُنّا جعلنا المسيح حقا ظافرا في قلوبنا، طافحا فينا فرحًا وبشرى ومنقذا إيانا من كل بلى. عندما قال الملاك للنسوة القديسات انه قد قام، ليس هو ههنا، قال لنا نحن المسيحيين: "غيّروا نفوسكم حتى تطلبوا المسيح في نفوسكم المتغيّرة. هو يدحرج الحجر عن باب كل قلب بقوة القيامة".

ماذا يقول المسيحيون اليوم؟ يقدمون أعذارًا: أنا ضعيف، انجرفت، زلقت، انا من تراب... وقعت في التجربة، غرّني المال، انجذبت بالشهوة... هذا كلام لم يرد في الإنجيل الذي به نؤمن. ما ورد في كتابنا ان المسيح حي واننا أحياء في اللحم والدم، وأن كلا منا مدعو أن يصير مسيحا منذ الآن. وأما هذه الهزالة المسيحية القائلة اننا سنخلص من بعد موت من بعد ان ندفن، وان لله الرحمة الكثيرة وانه شفوق، ولذلك لا بأس ان ننغمس في كل ما تطلبه نفوسنا الآن... هذه بالضبط خيانة يهوذا، هذه تزكية لكل خياناتنا.

المسيحي المؤمن لا يخاف من قبره ولا من موته ولا من الركام الذي تحت القبر. المسيحي المؤمن يهتم بأن يحيا مع المسيح. قال يوحنا الذهبي الفم: "قام المسيح وليس من ميت في القبور". هل نحيا نحن الآن وكأننا نؤمن حقا ان ليس من ميت في القبور، وان كلا منا تجاوز موته منذ الآن، وداس خطيئته، وصار مسيحًا منذ الآن؟ أهذه قناعتنا؟

هذا في كل حال إيماننا: المسيح قام وليس من ميت في القبور. مهمتنا ان نأتي معًا لنعلن قيامته ونبشّر ذوينا وأصدقاءنا بأنهم محضونون منذ الآن، محضونون من المسيح الظافر.

قام المسيح وليس من ميت في القبور.

قام المسيح وانت غلبت.

قام المسيح واستقرت الحياة.

قام المسيح والحجر قد دُحرج.

لماذا تطلبون الحي بين الأموات؟

لا يندبن أحد عن آثام لأن الصفح بدا من القبر.

 لا يخافن أحد من الموت لأن موت المخلّص قد حررنا. 

فلنسر في خطاه أُناسا قياميين.

جاورجيوس مطران جبيل والبترون وما يليهما (جبل لبنان).

living with dying

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This Week in the Movement

Posted on April 25, 2014

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MD politician and Death with Dignity supporter Heather Mizeur

Throughout the week, we keep people up-to-date about the Death with Dignity movement and other topics related to end-of-life care through Facebook, Twitter and Pinterest. Below are highlights from the last couple weeks.
Efforts regarding Death with Dignity:

• The Journal of the American Medical Association published an article on the changing legal climate for Death with Dignity.
• Maryland gubernatorial candidate Heather Mizeur made some waves by coming out strongly in support of Death with Dignity policy reform.
• An op-ed in the Johns Hopkins Newsletter outlined why physician-assisted death should be legalized.

Discussions about death, dying, and grieving:

• Green burials are a pretty new concept in the US. The documentary A Will for the Woods explores an intimate look at this burial option.
• A shorter documentary (but no less excellent), Good Grief, shared stories of real individuals grieving loss.
• A person living with a terminal illness explained why battle analogies aren't helpful when talking about cancer or other serious illnesses.
• Probably by happenstance, but almost in honor of National Healthcare Decisions Day, the Connecticut Senate advanced a bill to enhance documenting healthcare wishes through a new state MOLST program.
• Bloomberg presented visual data about "How Americans Die."

Life's too short (always take a moment to enjoy the little things):

• A fantastic mash-up: AT&True Detective.
• Sometimes animals knock kids over on purpose. (Disclaimer: the National Center doesn't support or condone cats plowing over babies.)

Posted on April 25, 2014

- See more at: http://www.deathwithdignity.org/2014/04/25/this-week-in-the-movement?utm_source=All+Things+Palliative+Daily+News&utm_campaign=7e768bee6e-_ATP_Daily_News_April_28_20144_28_2014&utm_medium=email&utm_term=0_4f2efd60ac-7e768bee6e-66566389#sthash.6L5yiBO3.dpuf

A critical view on legal barriers and the need for trust – the ATOME Slovakia National Symposium on Access to Opioid Medication

Posted on April 28, 2014 by pallcare

Eugenia Larjow, sociologist at the University Hospital of Bonn, Germany, and member of the ATOME (Access to Opioid Medication in Europe) Project Management Team.

Dr Ľubomír Okruhlica Director, Centre for Drug Dependence Treatment Bratislava, presented some epidemiological results based on the EU- funded project, Improvement of Access to Treatment for People with Alcohol- and Drug-Related Problems.
(Photograph: Katherine Pettus)

Nearly 60 people participated in the ATOME conference held in Bratislava on Tuesday, 25^th March 2014, including representatives of the Ministry of Health, physicians and experts from palliative care, pain management and harm reduction.

“At the beginning I was sceptical, but then I noted people look at me differently, not as a ‘drug addict’. My family accepted me back. I look and feel better. Two years ago I was on the street and on my own. Methadone saved me.”

This is one example of how patients in Slovakia assess their methadone maintenance treatment. Nevertheless, regulatory barriers such as formal documents increase the threshold for access to treatment. Absence of Opioid Agonist Therapy (OAT) in prison, no willingness to prescribe and no access to programmes outside Bratislava are some of the parameters that challenge substitution therapy in Slovakia. However, general epidemiological parameters show a good situation compared to other countries. The insurance system with OAT being free of charge was highlighted as a positive aspect of harm reduction in Slovakia.

Mortality Slide from Dr Okruhlica’s presentation

With regards to opioid therapy in palliative care, a lack of trust towards the expertise of palliative care professionals was demonstrated. Education and sustainability in palliative care services are necessary to handle ‘palliaphobia’. Establishment of networks would be very important. Changes related to prescription restrictions for palliative specialists and reimbursement of mobility costs would also improve the situation of palliative care in Slovakia.

The discussion about the review of the legislation related to opioid prescription, dispensing and use was an important part of the conference. A representative of the Ministry of Health emphasised the influence of European guidelines on Slovakian opioid regulations.

Professor Sheila Payne, President of the European Association for Palliative Care, concluded the conference by highlighting the main messages such as transfer of knowledge to relevant faculties at the universities and increases in the number of palliative care beds, but also revision of the legislation at least in some points.

To find out more…
Click here for more information about the ATOME project. You can also read several other posts on the EAPC blog about previous ATOME meetings. 

Lebanese center for palliative care welcomes internationally renowned expert

28 April 2014

 

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At the invitation of Balsam, palliative care expert Dr Frank Ferris has been in Beirut, participating in conferences and meeting with healthcare providers and policy makers involved in palliative care development in Lebanon.

Palliative care is underdeveloped in Lebanon – only last year palliative care gained officially recognition as a medical specialty and there are very few physicians and nurses trained in palliative care.
Balsam – The Lebanese Center for Palliative Care – is a non-governmental organisation that provides free palliative care and trains doctors and nurses in the discipline. Director of Balsam, Hibah Osman, the first licensed palliative care physician in Lebanon, also heads a newly established palliative care program at the American University of Beirut.
Dr Ferris, who is director of palliative medicine, research and education at OhioHealth, a large network of hospitals in the US, has been involved in palliative care development in a number of countries, and first visited Beirut in 2001 to raise awareness of palliative care. 
He latests visit also involved raising awareness, as well as introducing training programs, providing advice to government officials on a palliative care law and giving recommendations on how it can be funded. Dr Ferris also facilitated a workshop on 'Leadership development for hospital-based palliative care programs', with the aim of introducing healthcare providers to the skills necessary for building hospital based palliative care programs.

Dr Ferris and Dr Osman have also been raising awareness among the public through speaking to the local press.

In an interview with The Daily Star, they highlight the importance of palliative care and describe some of the barriers which currently exist in the country. For example, currently, insurance companies can deny coverage of medicine if the patient is transferred into palliative care.
They also highlight how medical advances and longer life-expectancies mean that there is an increasing need for palliative care, while illness still carries a stigma, leading to late diagnosis of diseases.

Read the full article on The Daily Star website and to find out more about Balsam and palliative care in Lebanon you can visit its website or read an interview with Loubna Batlouni and Mohammad Saab, part of the Balsam team, which ehospice published last year.

Mindfulness-Oriented Recovery Enhancement Ameliorates the Impact of Pain on Self-Reported Psychological and Physical Function Among Opioid-Using Chronic Pain Patients

• Eric L. Garland, PhD
,
• Elizabeth Thomas, MSW
,
• Matthew O. Howard, PhD

Received 21 November 2013; received in revised form 3 March 2014; accepted 2 April 2014. published online 28 April 2014.
Accepted Manuscript

• Abstract
• Full Text
• PDF
• Images
• References

Abstract 

Context.

Chronic pain impacts one-third of the U.S. population, and its effects are debilitating for individuals and costly to the medical system. Although opioids are commonly prescribed to address chronic pain, they confer risk for misuse and addiction, and may not fully restore life function – particularly with regard to psychosocial factors. Because of the multiplicity of impacts that chronic pain may have on daily functioning, broad-spectrum behavioral interventions are needed.

Objectives

The purpose of this study was to conduct follow-up analyses from a pilot randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE) to assess specific effects of MORE on various biopsychosocial aspects of pain-related impairment.

Methods

Chronic pain patients (N=115; mean age 48±14 years; 68% female) were randomly assigned to either eight weeks of MORE or to a support group (SG). Domains of pain-related functional interference were measured with the Brief Pain Inventory at pre- and post-treatment, and at a three-month follow-up. Treatment effects were analyzed with multivariate intention-to-treat models.

Results

MORE participants reported significantly greater reductions in functional interference than SG participants at post-treatment across all domains, including: general activity, mood, walking ability, normal work, relationships, sleep, and enjoyment of life. These effects were largely maintained by the three-month follow-up; however, general activity level and walking ability were no longer significant, indicating differential long-term effects between physiological and psychological functioning.

Conclusion

Findings demonstrate preliminary efficacy of MORE as a treatment for pain-related functional impairments, and suggest that effects may be more pronounced and durable for aspects of psychological function.

Key Words: mindfulness, chronic pain, function, impairment, opioid, quality of life

Spiritual distress of military veterans at the end of life

Bei-Hung Chang^a1a2 c1, Nathan R Stein^a3 and Lara M Skarf^a1

^a1 VA Boston Healthcare System, Boston, Massachusetts
^a2 Boston University School of Public Health, Boston, Massachusetts
^a3 Providence VA Medical Center, Providence, Rhode Island

Abstract

Objective: Although combat experiences can have a profound impact on individuals' spirituality, there is a dearth of research in this area. Our recent study indicates that one unique spiritual need of veterans who are at the end of life is to resolve distress caused by combat-related events that conflict with their personal beliefs. This study sought to gain an understanding of chaplains' perspectives on this type of spiritual need, as well as the spiritual care that chaplains provide to help veterans ease this distress.
Method: We individually interviewed five chaplains who have provided spiritual care to veterans at the end of life in a Veterans Administration hospital. The interviews were recorded, transcribed, and analyzed based on “grounded theory.”

Results: Chaplains reported that they frequently encounter veterans at the end of life who are still suffering from thoughts or images of events that occurred during their military career. Although some veterans are hesitant to discuss their experiences, chaplains reported that they have had some success with helping the veterans to open up. Additionally, chaplains reported using both religious (e.g., confessing sins) and nonreligious approaches (e.g., recording military experience) to help veterans to heal.

Significance of results: Our pilot study provides some insight into the spiritual distress that many military veterans may be experiencing, as well as methods that a chaplain can employ to help these veterans. Further studies are needed to confirm our findings and to examine the value of integrating the chaplain service into mental health care for veterans.

(Received January 21 2014)

(Accepted February 15 2014)

Keywords

• Spiritual distress;
• Religion;
• Spirituality;
• Veterans;
• End of life;
• War

Correspondence

^c1 Address correspondence and reprint requests to: Bei-Hung Chang, 150 S. Huntington Avenue, 152H, Boston, Massachusetts 02130. E-mail: bhchang@bu.edu

Spirituality in the context of life-threatening illness and life-transforming change

William C. Young^a1, Sheeba R. Nadarajah^a2, Perry R. Skeath^a3 and Ann M. Berger^a4 c1

^a1 Pain and Palliative Care Service, National Institutes of Health Clinical Center, Bethesda, Maryland
^a2 Department of Nursing, Bowie State University, Bowie, Maryland
^a3 Arizona Center for Integrative Medicine, University of Arizona, Tucson, Arizona
^a4 Pain and Palliative Care Service, National Institutes of Health Clinical Center, Bethesda, Maryland

Abstract

Objective: Individuals with life-threatening illness often engage in some form of spirituality to meet increased needs for meaning and purpose. This study aimed to identify the role of spirituality in persons who had reported positive, life-transforming change in relation to life-threatening cancer or cardiac events, and to connect these roles to palliative and supportive care.

Method: A purposive sample of 10 cardiac survivors and 9 cancer survivors was recruited. Once the participants had given informed consent and passed screening in relation to life-transforming change and distress, they engaged in a semistructured one-hour qualitative interview on the theme of how their life-transforming change occurred in the context of their life-threatening illness. In the present article, our phenomenological analysis focuses on participants' references to purpose and meaning in their lives, with particular attention to the role and context of participants' spirituality.

Results: Participants mentioned spirituality, meaning, and purpose in many contexts, including connecting with family and friends, nature, art, music, and sometimes creating a relationship with God. Participants often accessed spirituality by enhancing connections in their own lives: with a higher power, people, their work, or themselves. These enhanced connections gave participants greater meaning and purpose in their lives, and substantially helped participants to adjust to their life-threatening illnesses.
Significance of results: Understanding the roles and contexts of spirituality among patients with a life-threatening illness allows us to develop better palliative and supportive care plans. Spiritually oriented supportive care may include support groups, yoga, meditation, nature, music, prayer, or referral to spiritual or religious counselors. A quantitative scale is needed to help healthcare clinicians assess the spiritual and coping needs of individuals with life-threatening illness.

(Received January 17 2014)

(Accepted February 27 2014)

Keywords

• Spirituality;
• Cancer;
• Cardiac illness;
• Meaning and purpose;
• Qualitative research

Correspondence

^c1 Address correspondence and reprint requests to: Ann M. Berger, Pain and Palliative Care Service, National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 2-1733, Bethesda, Maryland 20892. E-mail: aberger@cc.nih.gov

“It's been quite a challenge”: Redesigning end-of-life care in acute hospitals

Alistair Hewison^a1 c1, Laura Lord^a1 and Cara Bailey^a1

^a1 Department of Nursing, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom 

Abstract

Objective: This paper reports the findings of an interview-based study undertaken to investigate the introduction of end-of-life (EoL) care pathways in three acute trusts, as part of a larger project examining service redesign. The aim was to examine the barriers to and facilitators of change.

Method: Twenty-one in-depth qualitative interviews were conducted with staff working in three National Health Service (NHS) acute hospital trusts. These staff members were involved in end-of-life care, and their accounts were analyzed to identify the key issues when introducing service changes in these settings.

Results: Thematic analysis revealed five major themes—two of which, leadership and facilitation, and education and training, indicate what needs to be in place if end-of-life care pathways are to be adopted by staff. 

However, the remaining three themes of difficult conversations, diagnosing dying, and communication across boundaries highlight particular areas of practice and organization that need to be addressed before end-of-life care in hospitals can be improved.

Significance of results: Organization of end-of-life care in acute hospitals is challenging, and care pathways provide a degree of guidance as to how services can be delivered. However, even when there is effective leadership at all levels of an organization and an extensive program of education for all staff support the use of care pathways, significant barriers to their introduction remain. These include staff anxieties concerning diagnosing dying and discussing dying and end-of-life care planning with patients and their families. It is hoped these findings can inform the development of the proposed new care plans which are set to replace end of life care pathways in England.

(Received November 19 2013)

(Accepted January 19 2014)

Keywords

• End of life;
• Hospitals;
• Staff experience;
• Qualitative methods

Correspondence

^c1 Address correspondence and reprint requests to: Alistair Hewison, Department of Nursing, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT United Kingdom. E-mail: a.hewison@bham.ac.uk

Palliative chemotherapy

Optimising end of life care requires an individualised approach

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2312 (Published 25 March 2014)

Cite this as: BMJ 2014;348:g2312

1. Hilde M Buiting, researcher in palliative decision-making1,
2. Gabe S Sonke, medical oncologist2

Author Affiliations

1. h.buiting@iknl.nl

Wright and colleagues conclude that patients receiving palliative chemotherapy who have an estimated life expectancy of six months are more likely than those not receiving palliative chemotherapy to experience intensive medical end of life care.

The authors previously showed that end of life discussions in early stage disease are associated with decreased “aggressive” care.

We support the identification of early predictors for intensive medical …

The end of life

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2261 (Published 26 March 2014)

Cite this as: BMJ 2014;348:g2261

1. Leigh Page, freelance writer, 2525 North Talman Avenue, Chicago, Illinois, USA

1. leighpage@comcast.net

US physicians are more pressed than ever to deal with end of life care. Leigh Page looks at the issues

Increasingly, US physicians face legal risks for doing too much or too little to help patients with end of life issues. On one hand, doctors are under more pressure to hold discussions with people who are diagnosed with terminal illnesses—exploring whether they would want to stop treatment if it became ineffective. In that case, the patient would shift to palliative care, which involves pain medications and other therapies to enhance quality of life.

On the other hand, physicians may have terminally ill patients who are untreatable and want to die, but assisting in their suicide is illegal in most US states. In a few cases, physicians have been criminally convicted and sent to prison for helping a patient die.

Even talking about end of life issues can be distressing for physicians, because their overriding concern is to heal patients, said Timothy E Quill, a palliative care specialist in Rochester, New York. “When you’ve been fighting for a patient for a long time, it can be really hard to give up on treatment,” said Quill, who directs the Center for Ethics, Humanities and Palliative Care at the University of Rochester School of Medicine.

Quill said there are negative consequences, however, if physicians avoid talking about end of life issues with patients—as is often the case. Patients may never have the chance to choose options that could ease their deaths. And if they can’t talk about their desire for suicide, they are cut off from exploring other options, such as taking antidepressants or stronger pain medications.

Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2197 (Published 31 March 2014)

1. Richard Price, intensivist1,
2. Graeme MacLennan, senior statistician2,
3. John Glen, intensivist3
4. on behalf of the SuDDICU collaboration

Author Affiliations

1. Correspondence to: R Price rjp@doctors.org.uk

• Accepted 3 March 2014

Abstract

Objectives To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis.

Design Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence.

Inclusion criteria Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo.

Results Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). 

When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain.

Conclusion Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.

Increased Risk of Acute Cardiovascular Events After Partner BereavementA Matched Cohort Study

Iain M. Carey, MSc, PhD¹; Sunil M. Shah, MBBS, MSc, FFPH¹; Stephen DeWilde, MBBS, MD, FRCGP¹; Tess Harris, MBBS, MSc, MD, MRCGP¹; Christina R. Victor, MPhil, PhD²; Derek G. Cook, MSc, PhD¹

[+] Author Affiliations

JAMA Intern Med. 2014;174(4):598-605. doi:10.1001/jamainternmed.2013.14558.

ABSTRACT

Importance  The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement.

Objective  To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day.

Design, Setting, and Participants  Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement.

Exposures  Partner bereavement.
Main Outcomes and Measures  The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease.

Results  Within 30 days of their partner’s death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days.

Conclusions and Relevance  This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

NPR’s "This American Life" to look at hospice

25 April 2014

 

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  This American Life producer Nancy Updike spent nine days at Kaplan House.

This American Life producer Nancy Updike spent nine days at Kaplan House.

Care Dimensions' Kaplan House in Massachusetts to be featured on National Public Radio this weekend - April 26-27, 2014.

In February, This American Life producer Nancy Updike spent nine days at Kaplan House interviewing patients, families and following Care Dimensions clinical staff as they cared for patients.

The resulting program, called "Death and Taxes" will air this weekend on April 26 and 27 on Boston radio stations WBUR and WGBH. The program promises to give a glimpse into the world of hospice and end-of-life caregivers.
  Care Dimensions staff were honored to be chosen to participate in this national broadcast heard on 500 stations and by more than two million listeners. We hope it will help educate the public about the vital role of hospice care and demystify the dying process.
The podcast of This American Life will be available for download once the broadcast airs; visit This American Life website.

A new film by Yasmin Gunaratnam explores the social pain often experienced by migrants at the end of life.

Two Sighs is a short film made by researcher and lecturer, Yasmin Gunaratnam, and is based on interviews conducted as part of her Case Stories project. 

Case stories is a transdisciplinary project on migration, dying and care, funded by a British Academy Fellowship.

Using oral histories, archival research, stories and art, the aim is to better describe and understand 'social pain' at the end of life for migrants. Social pain refers to the suffering caused by social inequalities, injustice and exclusion.

The project is also building a digital archive of stories of transnational dying that can be used in teaching and training.

Talking to ehospice last year about the project, Yasmin explained: "At a very basic level the Case Stories project is using stories and art to try and encourage thinking about the ways in which social pain can manifest at the end of a life." 

The film tells three stories, starting with Harshini's story about caring for her mother with dementia and how religious and cultural differences can affect symptoms and care needs.

Following this is the poem 'Dust to Dust', a migration journey from arrival in the UK, to industrial injury and the lure of 'home' - mango trees, rivers, sea - at the end of life.

In the final scene, 'A Face', a hospice nurse remembers caring for a Ugandan woman with AIDS-related dementia who did not speak English, and the difficulties in bridging their differences to understand each other.

You can view the film Two Sighs on YouTube or visit the Case Stories website to find out more about Yasmin's project.