Understanding Palliative Care and Hospice: A Review for Primary Care Providers

Palliative care provides invaluable clinical management and support for patients and their families. For most people, palliative care is not provided by hospice and palliative medicine specialists, but rather by their primary care providers. The recognition of hospice and palliative medicine as its own medical subspecialty in 2006 highlighted the importance of palliative care to the practice of medicine, yet many health care professionals harbor misconceptions about palliative care, which may be a barrier to ensuring that the palliative care needs of their patients are identified and met in a timely fashion. When physicians discuss end-of-life concerns proactively, many patients choose more comfort-focused care and receive care more aligned with their values and goals. This article defines palliative care, describes how it differs from hospice, debunks some common myths associated with hospice and palliative care, and offers suggestions on how primary care providers can integrate palliative care into their practice.     

Patient Reported Outcome Measures in Chronic Neuropathic Pain Clinical Trials – A Systematic Literature Review

In neuropathic pain clinical trials, the patient's perspective is often insufficiently reflected focusing mainly on pain intensity. Comparability of outcome assessment is limited due to heterogenous patient reported outcome measures (PROMs).The MEDLINE, CENTRAL, and Embase databases and reference lists of published meta-analyses were searched. Randomized controlled studies assessing treatment efficacy of drugs for chronic neuropathic pain were included. PROMs were assigned to recommended IMMPACT/NeuPSIG domains: pain intensity, pain other aspects, physical functioning, emotional functioning, global improvement and satisfaction, adverse events, participant disposition. Domains and PROMs were compared regarding the publication year and methodological quality of the studies.Within the 251 included studies 200 PROMs were used with 27 being recommended by IMMPACT/NeuPSIG. The number of domains was higher in high/moderate quality studies. The (sub-) domains ‘physical functioning’, ‘global improvement and satisfaction’, and ‘neuropathic pain quality’ were assessed more frequently in high/moderate quality studies and those published after 2011. Recent studies and those of better quality more often used the recommended PROMs.Although neuropathic assessment via PROMs has improved, there is still a high heterogeneity. A standardized core set of outcome domains and should be defined to improve neuropathic pain treatment and to achieve better comparability of clinical trials.PerspectiveThis systematic literature review assesses the use of patient reported outcome measures (PROMs) in chronic neuropathic pain. The results show that there is still a high heterogeneity, highlighting the need for a standardized core set of outcome domains and PROMs to improve comparability of clinical trials and neuropathic pain treatment.     

Pregnancy-Related Spontaneous Coronary Artery Dissection: A Case Series and Literature Review

Background

Cardiac emergencies during pregnancy are rare but have significant associated morbidity and mortality when they do occur. The emergency physician must not only be aware of potentially life-threatening conditions in the pregnant woman, but also know the emergent management and treatment of these conditions to avoid worsening of the underlying condition. Pregnancy-related spontaneous coronary artery dissection has been described in the cardiology literature, but is not well-known in emergency medicine literature.

Segway® Personal Transporter-Related Injuries: A Systematic Literature Review and Implications for Acute and Emergency Care

Background

The Segway® Personal Transporter? (SPT) is used widely as a means of transport for city sightseeing tours, law enforcement, and professionals working in large facilities and factories.

Patients’ Experiences After Attempted Suicide: A Literature Review

The aim of this study has been to synthesize research on suicidal patients’ experiences of the suicide process. A literature search was performed in CINAHL, PubMed, and PsycINFO, and the analysis of the 15 articles covered was based on meta-synthesis. Patients experience a wide variety of feelings regarding their situation during the suicide process, and these exist on two levels: they relate to the different aspects of care that the patients receive and the patients’ need to communicate with others and regain hope. The patients in this study described the struggle to maintain hope when life became too difficult and their suffering despite a sense of security, and they sought to achieve emotional balance. A good understanding of how suicidal individuals live with and manage suicidal ideation, while maintaining hope is important for planning effective nursing care. Further research from the patient perspective is needed to further develop psychiatric care for people at risk of suicide.     

Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study

Objective

To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials.

Use of α2-Adrenergic Agonists to Improve Surgical Field Visibility in Endoscopy Sinus Surgery: A Systematic Review of Randomised Controlled Trials

Purpose

We assessed the evidence for the use of α₂-adrenergic agonists (A2AAs) in bleeding control and field quality in endoscopic sinus surgery.

Understanding Nurses’ Knowledge and Attitudes Toward Pain Assessment in Dementia: A Literature Review

BackgroundPain is underrecognized and undertreated in patients with dementia. It has been suggested that nurses’ attitudinal barriers may contribute to the challenges surrounding pain assessment and management in dementia.AimsThis integrative literature review aims to identify and explore nurses’ knowledge and attitudes towards pain assessment in older people with dementia and how it may affect pain management in this patient group.MethodElectronic searches were conducted in Web of Science, MEDLINE, Scopus, ProQuest, PubMed, and EBSCOhost from January 2008 to December 2018 for articles specifically focusing on nurses’ knowledge and attitudes towards pain assessment in older patients with dementia.ResultsTen studies were included in the review after meeting the inclusion criteria. Data extracted from each study included study design, aims and objectives, setting/sample, findings, and limitations. Patients with dementia are at greater risk of experiencing underassessment, undertreatment, and delayed treatment of pain due to nurses’ knowledge deficits and uncertainty in the decision-making process. Nurses see providing comfort and reducing pain as ethical obligation. However, they find pain assessment a challenge due to the complexity of recognizing painful behaviors, and difficulty differentiating between pain and behavioral disturbances in dementia. Poor multidisciplinary communication, time constraints, and workload pressure, as well as uncertainty about opioid use, are important barriers to effective pain assessment and management among patients with dementia.ConclusionIt is essential that nurses gain confidence in distinguishing signs and symptoms of pain from behavioral changes in dementia. It is important to improve interdisciplinary communication and to get physicians to listen and prioritize pain assessment and management.     

Differences in Health Care Utilization in the Year Before Suicide Death: A Population-Based Case-Control Study

ObjectiveTo compare health care usage between suicide decedents and living controls in the year before suicide in a large representative US population.Patients and MethodsCases (n=1221) and controls (n=3663) belonged to an integrated health care system from January 1, 2009, through December 31, 2014. Cases and controls were matched for age and sex in a 1:3 ratio, with diagnostic and/or billing codes used to enumerate and classify health care visits in the year before the index suicide. Matched analysis via conditional logistic regression related odds of suicide to visit type. A generalized estimating equation model was used to compare timing and frequency of visits between cases and controls.ResultsIn the year before death, cases had an increased odds of both inpatient hospitalizations and emergency department nonmental health visits (odds ratio [OR], 1.55; 95% CI, 1.27-1.88; P<.001 and OR, 1.42; 95% CI, 1.26-1.60; P<.001) but not outpatient nonmental health visits (OR, 1.00; 95% CI, 0.99-1.01; P=.63). Decedents increased health care utilization closer to suicide death and had significantly more health care visits than did controls 3 months before suicide (6 vs 2; P=.01) but not 9 to 12 months before suicide (4 vs 2; P=.07). At all time points, cases used more mental health care services than did controls.ConclusionCompared with controls, suicide decedents had emergency department visits and more inpatient hospitalizations, both mental health and nonmental health related. As death approached, cases' frequency of health care usage increased. The only category in which cases and controls did not differ was in the frequency of outpatient nonmental health visits.     

Mental Health Researchers’ Views About Service User Research: A Literature Review

Services users are becoming actively involved in mental health research. How this is perceived by other researchers is not well known. The aim of this article is to review the international literature exploring other mental health researchers’ views of service users conducting research, between 1996 and 2016. Searches of multiple databases (PubMed, PsycINFO, CINAHL, and Google Scholar) were undertaken. Combinations of terms related to service user research and mental health researcher perspectives, views, and attitudes were used. Manual inquiry of reference lists was also undertaken. Relevant papers were coded by topic, location, study design, and other dimensions. Five articles met inclusion criteria. Most referred to perceived benefits, such as greater validity of research findings, challenges of collaborating with service users, and the validity of research findings. There was some evidence of more openness to mental health service users providing suggestions, preferably in early stages of the research process. Reluctance to co-research with service users was reported. There is limited research directly addressing other mental health researchers’ views about service user research; barriers to inclusion (whether involvement, co-production or user-controlled) and creating incongruence with health policy statements. Further research to more fully understand these attitudes and how they might be influenced is warranted.     

Opportunities for Palliative Care in Patients With Burn Injury—A Systematic Review

ContextPatients with significant burn injuries likely have palliative care needs.ObjectivesWe performed a systematic review of existing evidence concerning the palliative care needs of burn patients.MethodsThrough November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains.ResultsOur searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains—processes of care, psychologic symptoms, social aspects, and end of life—were addressed by studies but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments.ConclusionMost existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.     

Neuropathic Pain in Low Back-Related Leg Pain Patients: What Is the Evidence of Prevalence,Characteristics, and Prognosis in Primary Care? A Systematic Review of the Literature

This systematic review synthesizes literature describing prevalence, characteristics, and prognosis of low back-related leg pain (LBLP) patients with neuropathic pain in primary care and/or similar settings. Inclusion and exclusion criteria were developed and used by independent reviewers to screen citations for eligibility. The initial search yielded 24,948 citations; after screening 12 studies were included. Neuropathic pain was identified using case ascertainment tools (n = 5), clinical history with examination (n = 4), and using LBLP samples assumed neuropathic (n = 3). Neuropathic pain prevalence varied from 19% to 80%. There was consistent evidence for higher back-related disability (n = 3), poorer health-related quality of life (n = 2), and some evidence for more severe depression (n = 2), anxiety (n = 3), and pain intensity (n = 4) in patients with neuropathic pain. Results were less consistent when cases were identified through clinical history with examination than those identified using case ascertainment tools. Prognosis (n = 1) of LBLP patients with neuropathic pain was worse compared with those without, in all outcomes (leg pain intensity, leg and back-related disability, self-reported general health) except back pain intensity. No studies described prognostic factors. This systematic review highlights the evidence gap in neuropathic pain in LBLP in primary care, especially with respect to prognosis.

Health Care Professionals’ Knowledge and Attitudes Toward Physical Activity in Cancer Patients: A Systematic Review

ObjectivesThe purpose of this study was to, combine current available literature across health professionals to determine commonalities and differences between knowledge and attitudes of physical activity (PA) and its importance within the cancer population. It aimed to identify any gaps in the literature to inform future study directions to enhance PA participation and improve health outcomes and quality of life.Data SourcesDesign: systematic review. Data sources: Google Scholar, EBSCO, PubMed, Scopus, Web of Science. Inclusion criteria: survey-based studies specifically reporting PA levels for both cancer patients and survivors from the perspective of oncology health care professionals. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used to guide this review. The initial search highlighted 15,342 articles and returned 190 articles with relevant titles, of which 20 met the eligibility criteria; 15.8% of cancer patients reported to meeting PA guidelines during treatment and 36.5% after treatment. On average 58.1% of health care professionals self-reported discussing PA with their cancer patients, with the average referral rate to an exercise specialist or rehabilitation program being 18.3%.ConclusionOnly a limited number of health care professionals are initiating a discussion about PA with their cancer patients. Some health care professionals reported limited knowledge of PA guidelines for cancer patients. Their own personal PA levels do not seem to be associated with whether they discuss PA with their patients. Common barriers to providing PA advice were experienced across all health care professions such as time, limited referral pathways, and patient interest. Future research should be carried out to substantiate these barriers and discover which strategies could be implemented to improve the levels of PA discussions and referrals within clinical practice.Implications for Nursing PracticeGiven the position nurses hold within the health care system, it would be beneficial to upskill and improve their understanding of PA and exercise as medicine for the cancer population. This has enormous potential that could enhance PA advice and boost referrals to exercise professionals improving the health and quality of life of the cancer population.     

Advance Care Planning in Early Stage Dementia

Dementia is a chronic illness that involves progressive loss of cognitive and functional abilities. In the early stages, persons with dementia actively face their cognitive decline, adjust to cognitive loss, and are able to take an active role in discussing values and preferences for future care. Preparing patients and families for what to expect in the course of dementia is vital in ascertaining an individual’s wishes regarding supportive and life-sustaining interventions. Nurse practitioners in primary care have a responsibility to initiate advance care planning conversations with persons in the early stages of dementia.     

The Effectiveness of Psychosocial Interventions for Psychological Outcomes in Pediatric Oncology: A Systematic Review

Context

This review summarizes the current randomized controlled trials literature on psychological and physical outcomes of psychosocial interventions in pediatric oncology.