Journal of palliative medicine
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Patients with metastatic nonsmall cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) mutations benefit from improved survival and quality of life with EGFR-directed therapy. We sought to explore if these improvements in cancer care impacted the delivery of end-of-life (EOL) care in this population. ⋯ Patients with metastatic NSCLC harboring EGFR mutations had high rates of chemotherapy use and hospital admissions in the last month of life, and many died in the hospital. Hospital admissions near the EOL and short admissions to hospice are indicators of poor quality EOL care and are likely a result of prolonged chemotherapy administration in this population. Thus, current healthcare delivery models may be insufficient to provide comprehensive EOL care for patients with EGFR mutations.
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Current methods for identifying patients at risk of dying within six months suffer from clinician biases resulting in underestimation of this risk. As a result, patients who are potentially eligible for hospice and palliative care services frequently do not benefit from these services until they are very close to the end of their lives. ⋯ This prospective approach appears to provide a method to identify patients with CHF who would potentially benefit from a clinical evaluation for referral to hospice care or for a palliative care consult due to high predicted risk of dying within 180 days after discharge from a hospital. This approach can provide a model to match at-risk patients with evidenced-based care in a more consistent manner. This method of identifying patients at risk needs further prospective evaluation to see if it has value for clinicians, increases referrals to hospice and palliative care services, and benefits patients and families.
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Palliative care clinicians are increasingly involved in the care of elderly patients suffering from chronic malignant and nonmalignant illnesses, of which neuropathic pain is a prevalent problem. As a person becomes more frail, pain medications such as opioid analgesics and adjuvant pain medications can result in unwanted effects such as sedation, confusion, and increased risk of falls. ⋯ Methadone is an opioid analgesic that is effective in the treatment of neuropathic pain, is excreted by the bowels, is highly lipophilic, and can be administered through the oral, buccal, or sublingual routes. We present three cases highlighting the use of low-dose adjuvant methadone to manage complex neuropathic pain in the frail elderly.
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The Center for Medicare Services (CMS) requires palliative care involvement for patients who receive a destination therapy ventricular assist device (VAD). Creative solutions are needed to meet this requirement in the context of limited palliative care resources. ⋯ Nurses with basic palliative care skills can conduct scripted preparedness planning conversations. These conversations are well received by patients, satisfy CMS requirements, and provide an alternative to full consults for resource-limited programs. Additional research is needed to compare outcomes between nurse visits and traditional consults.