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Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.
DeFilippis, EM, Nakagawa, S, Maurer, MS, Topkara, VK
Journal of the American Geriatrics Society. 2019;(11):2410-2419
Abstract
OBJECTIVES To review the literature and summarize the evidence for left ventricular assist device (LVAD) use in older adults (aged >75 years), highlighting patient selection, day-to-day life with an LVAD, age-specific complications, and end-of-life considerations. DESIGN Contemporary review of current literature on LVAD therapy in older adults. RESULTS There is a paucity of data on LVAD use and outcomes in adults older than 75 years and even less commonly are such devices implanted in those older than 80 years. Candidates and recipients of this age often have multiple chronic conditions and extracardiac impairments, which can negatively affect their short-term outcomes and daily experience following LVAD implantation. Therefore, selection prior to implant should incorporate end-organ function, nutritional status, measures of frailty, neurocognitive status, and social support, among others, to determine the patient population most likely to benefit from such therapy. CONCLUSION When LVAD therapy is utilized in an older adult, the needs for multidisciplinary team management and expertise in palliative care are essential. More age-specific outcome data are required to help inform providers, patients, and caregivers. J Am Geriatr Soc 67:2410-2419, 2019.
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2.
Image-Guided Palliative Interventions.
Requarth, JA
The Surgical clinics of North America. 2019;(5):921-939
Abstract
This article reviews a few surgical palliative care procedures that can be performed by surgeons and interventional radiologists using image-guided techniques. Treatment of recurrent pleural effusions, gastrostomy feeding tube maintenance, percutaneous cholecystostomy, and transjugular intrahepatic portosystemic shunts (TIPS) with embolotherapy of bleeding stomal varices is discussed.
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3.
Low reported taste function is associated with low preference for high protein products in advanced oesophagogastric cancer patients undergoing palliative chemotherapy.
de Vries, YC, Boesveldt, S, Kampman, E, de Graaf, C, Winkels, RM, van Laarhoven, HWM
Clinical nutrition (Edinburgh, Scotland). 2019;(1):472-475
Abstract
BACKGROUND & AIMS Cancer patients undergoing palliative chemotherapy can experience a variety of chemosensory and food preference changes which may impact their nutritional status and quality of life. However, evidence of these changes in oesophagogastric cancer (OGC) patients is currently mostly qualitative and not supported by quantitative data. The aim of this study was to assess how self-reported and objective taste and smell function and food preferences change over time during chemotherapy in OGC patients. METHODS This observational study included 15 advanced OGC patients planned for first line treatment with capecitabine and oxaliplatin. Participants completed two test sessions scheduled before start of cytotoxic treatment and after two cycles. Self-reported and objective taste and smell function and the macronutrient and taste preference ranking task were conducted at each test session. RESULTS Self-reported taste and smell did not change upon chemotherapy. Objective taste function decreased during chemotherapy, although this was not statistically significant (p = 0.06), objective smell function did not change. Before and during chemotherapy, high protein foods were preferred over high carbohydrate and over low energy products, but food preferences did not change over time. A lower self-reported taste function correlated with a lower preference for high-protein products (ρ = 0.526, p = 0.003). CONCLUSION This study suggests that objective taste function decreases during chemotherapy in OGC patients, but not smell function. A low reported taste function was related to a lower preference for high-protein products.
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4.
A supportive care intervention for people with metastatic melanoma being treated with immunotherapy: a pilot study assessing feasibility, perceived benefit, and acceptability.
Lacey, J, Lomax, AJ, McNeil, C, Marthick, M, Levy, D, Kao, S, Nielsen, T, Dhillon, HM
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2019;(4):1497-1507
Abstract
INTRODUCTION Increasing numbers of metastatic melanoma (MM) patients are receiving immunotherapy treatment, including pembrolizumab, and the impact on their well-being is underexplored. OBJECTIVES To assess the feasibility of a multimodal supportive care program to MM patients being treated with pembrolizumab. METHODS This pre-post-test feasibility cohort study recruited MM participants treated with pembrolizumab: (i) supportive care intervention with usual care and (ii) usual care. The intervention comprised comprehensive medical assessment by supportive care physician (SCP), exercise physiologist (EP), and dietitian then a tailored supportive care program. Programs included exercise, dietary advice, non-invasive complementary therapies, and psychology consultation. Outcome measures included adherence, patient-reported symptoms, anxiety and depression, and toxicity. Descriptive data are reported. RESULTS We recruited 28 participants: 13 intervention and 15 control; three did not complete the study. Most were male, with median age 66 (range 42-85) years. All intervention participants completed baseline assessments with SCP, EP, and dietitian. Two missed follow-up with EP or dietitian. Symptoms most troubling at baseline were as follows: fatigue (n = 6), sleep (n = 6), general aches and pains (n = 5), and memory (n = 4). All intervention participants were prescribed 16 exercise sessions; 8 (50%) completed all; overall exercise adherence was 85%. Integrative therapies were accessed by 85% (11) participants. Immunotherapy-related adverse event rates were low and SCP consultation identified symptoms not captured by CTCAE 4.0. CONCLUSIONS A holistic supportive care intervention tailored to individual needs is feasible. The symptom burden in MM patients was low. Further investigation of the intervention is warranted, focused on populations with higher symptom burden to improve outcomes.
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Conservative management for patients with chronic kidney disease refusing dialysis.
Castro, MCM
Jornal brasileiro de nefrologia. 2019;(1):95-102
Abstract
Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.
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6.
Palliative pelvic exenteration: A systematic review of patient-centered outcomes.
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European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2019;(10):1787-1795
Abstract
OBJECTIVE Palliative pelvic exenteration (PPE) is a technically complex operation with high morbidity and mortality rates, considered in patients with limited life expectancy. There is little evidence to guide practice. We performed a systematic review to evaluate the impact of PPE on symptom relief and quality of life (QoL). METHODS A systematic review was conducted according to the PRISMA guidelines using Ovid MEDLINE, EMBASe, and PubMed databases for studies reporting on outcomes of PPE for symptom relief or QoL. Descriptive statistics were used on pooled patient cohorts. RESULTS Twenty-three historical cohorts and case series were included, comprising 509 patients. No comparative studies were found. Most malignancies were of colorectal, gynaecological and urological origin. Common indications for PPE were pain, symptomatic fistula, bleeding, malodour, obstruction and pelvic sepsis. The pooled median postoperative morbidity rate was 53.6% (13-100%), the median in-hospital mortality was 6.3% (0-66.7%), and median OS was 14 months (4-40 months). Some symptom relief was reported in a median of 79% (50-100%) of the patients, although the magnitude of effect was poorly measured. Data for QoL measures were inconclusive. Five studies discouraged performing PPE in any patient, while 18 studies concluded that the procedure can be considered in highly selected patients. CONCLUSION Available evidence on PPE is of low-quality. Morbidity and mortality rates are high with a short median OS interval. While some symptom relief may be afforded by this procedure, evidence for improvement in QoL is limited. A highly selective individualised approach is required to optimise the risk:benefit equation.
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7.
Enhancing the decision-making process when considering artificial nutrition in advanced dementia care.
De, D, Thomas, C
International journal of palliative nursing. 2019;(5):216-223
Abstract
BACKGROUND Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family's requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments. AIM: This literature review aims to evaluate the evidence to support the use and non-use of ANH. METHOD A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices. CONCLUSION This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.
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8.
A hunger for hunger: a review of palliative therapies for cancer-associated anorexia.
Childs, DS, Jatoi, A
Annals of palliative medicine. 2019;(1):50-58
Abstract
Cancer-associated anorexia, or loss of appetite, is prevalent, distressing to patients and their families, and associated with poorer outcomes in patients with advanced cancer. A well-defined therapeutic strategy remains to be defined. We present here a review of appetite loss in cancer patients with a summary of how best to manage this symptom.
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9.
Integration of palliative, supportive, and nutritional care to alleviate eating-related distress among advanced cancer patients with cachexia and their family members.
Amano, K, Baracos, VE, Hopkinson, JB
Critical reviews in oncology/hematology. 2019;:117-123
Abstract
Advanced cancer patients with cachexia and their families can suffer from eating-related distress. This complex entity encompasses patients' struggle to nourish themselves, emotional and social consequences of their inability to maintain food intake, and profound disturbance in family relationships. With evidence-based nutritional care, as well as symptom management to enable food intake, cachexia can be mitigated to some degree. In addition, patients and families require psychosocial support and education to understand and cope with this condition. Only by taking an integrated approach can health care teams alleviate eating-related distress, improve quality of life (QOL), reduce interpersonal conflicts, and alter perceptions of nutritional neglect for patients and families. However, few studies have investigated eating-related distress among patients and families. The aim of this narrative review is to describe what is known about eating-related distress and the roles of integrated palliative, supportive, and nutritional care in improving QOL of patients and families.
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10.
Palliative Management of Gastric and Esophageal Cancer.
Halpern, AL, McCarter, MD
The Surgical clinics of North America. 2019;(3):555-569
Abstract
In patients with advanced esophageal or gastric cancer, it is highly likely that palliation of symptoms will become a focus of treatment. Dysphagia and obstruction are the most common complaints, and many of these patients can be treated with endoscopic interventions to alleviate symptoms. Bleeding, perforation, and nutritional issues are common problems. Attempts at palliation should be guided by thoughtful discussions regarding patients' goals of care. Owing to the high morbidity and mortality in patients with limited life expectancy, a strategy of working from the least invasive to the most invasive interventions should be guided by the patient's goals.