Adverse effects of opioids on the central nervous systems of palliative care patients

Opioids, defined as drugs that stimulate opioid receptors, are primarily used in the treatment of moderate to severe pain. They induce central nervous system (CNS) adverse effects which can be divided into three groups. The first group includes effects that lower the level of consciousness-sedation, drowsiness and sleep disturbance. The second group affects the thinking process and the ability to react-cognitive impairment, psychomotor impairment, delirium, hallucinations, dreams and nightmares. The third group is of the direct toxic effects of opioids on neurons and includes myoclonus (perhaps), hyperalgesia and tolerance. This review addresses the incidence, possible mechanisms, and treatment of each of these groups of opioid-induced adverse effects.     

Nurses' attitudes to palliative care in nursing homes in Western Australia

Nursing homes are one of the care settings in Western Australia where older people may spend their final years. Residents should be able to receive palliative care where appropriate, but this type of care is not always available at some nursing homes in the state. This study investigated nurses' attitudes to palliative care in nursing homes by examining their cognitive, affective and behavioural information. A sample of 228 nurses working in nursing homes completed a questionnaire, using a free response methodology. Results showed that participants had either a positive or negative attitude to palliative care. Cognitive and affective information significantly and independently predicted the attitudes of nurse, whereas knowledge of palliative care did not contribute significantly to these attitudes. Nurses currently working in palliative care were more positively disposed towards such care, but this disappeared when they ceased working in the area. There is an emphasis on education in the literature which does not take into account the beliefs and emotions of the nurse. Therefore, there is a need to consider these in undergraduate and postgraduate training for nurses. Current experience is also important in palliative care education. The results obtained from nurses in this study should be incorporated into policy for introducing palliative care into nursing homes and used to provide support and assistance to nurses working in this field.     

Hospital doctors' attitudes towards palliative care in Germany

Experts from different areas strongly criticize the current level of palliative care in Germany, both inpatient and home care services. Apart from the experts' opinions, little is known in this context about the perspectives of hospital doctors working in different disciplines, such as surgery, internal medicine, gynaecology or anaesthesia. These doctors presumably treat many incurably ill patients with palliative care needs, but they usually have very little experience in palliative medicine. Their attitudes are particularly important because they are affected by the criticism and by future improvement strategies. To study their viewpoints, questionnaire surveys in five hospitals in the federal state of Brandenburg were performed, with 203 (69%) physicians participating. The results showed that the level of palliative care in hospitals was graded better than in the home care setting. Main needs for improvement were seen in the psychosocial support services and in the co-operation with outpatient services. In [corrected] the hospital physicians' view, palliative nursing care was of a higher standard than medical aspects [corrected] of care [corrected] The physicians showed great interest in improving their knowledge of [corrected] palliative care and in new specialist palliative care services. The conclusions were that three main strategies for improvement should be embarked on: (1) the establishment of integrated care systems to overcome financial and structural barriers between in- and outpatient care; (2) the establishment of further specialist palliative care services (eg, hospital-based palliative care teams); and (3) better education in palliative medicine.     

Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients

This study assessed the effect of opioid treatment on ventilation in dyspneic palliative care patients who received symptomatic treatment with strong opioids. The assessments measured changes in peripheral arterial oxygen saturation (SaO(2)), transcutaneous arterial pressure of carbon dioxide (tcPCO(2)), respiratory rate (f), and pulse rate (PF) during the titration phase with morphine or hydromorphone. The aims of the study were to verify the efficacy of opioids for the management of dyspnea, assess the effect on ventilation, and show whether nasal O(2) insufflation before opioid application leads to a decrease in the intensity of dyspnea. Eleven patients admitted to our palliative care unit were included in this prospective, nonrandomized trial. At admission, all patients suffered from dyspnea. tcPCO(2), SaO(2), and PF were measured transcutaneously by means of a SenTec Digital Monitor (SenTec AG, Switzerland). During O(2) insufflation, the intensity of dyspnea did not change. In contrast, the opioid produced a significant improvement in the intensity of dyspnea (P=0.003). Mean f decreased as early as 30 minutes after the first opioid administration, declining from 41.8+/-4.7 (35.0-50.0) to 35.5+/-4.2 (30.0-40.0), and after 90 minutes, to 25.7+/-4.5 (20.0-32.0) breaths/min. Other monitored respiratory parameters, however, showed no significant changes. There was no opioid-induced respiratory depression.     

Knowledge, beliefs, and concerns about opioids, palliative care, and homecare of advanced cancer patients: a nationwide survey in Japan

Purpose  

Patients’ knowledge, beliefs, or concerns about opioids, palliative care, and homecare can be potential barriers to providing quality palliative care. The primary aim of this study was to clarify knowledge about opioids, beliefs about palliative care, and concerns about homecare in advanced cancer patients.     

Older adults' attitudes to death, palliative treatment and hospice care

BACKGROUND: Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by age-related differences in attitudes to end-of-life care. OBJECTIVE: To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. DESIGN: Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. SETTING: General practices in London. SUBJECTS: 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. METHODS: A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. RESULTS: Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged >74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. CONCLUSIONS: The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.     

Pediatric nurses' attitudes toward hospice and pediatric palliative care

Several studies have investigated nurses' attitudes toward hospice and palliative care for adults, yet little information exists about pediatrics. Assessing pediatric nurses' attitudes is especially important in Florida, where a publicly funded pediatric palliative care program operates in eight cities across the State. The aims of this study were 1) to assess the attitudes toward hospice and palliative care, and 2) to examine the associations between sociodemographic and nursing care factors and nurses' attitudes toward hospice and palliative care. A cross-sectional research design using online and mail-in survey data was used to address the study aims. Surveys were conducted with 279 pediatric nurses across Florida. Bivariate results showed there were significant differences between the attitudes of pediatric nurses employed in a city with a pediatric palliative care program versus those not employed in a program site (p = 0.05). Multivariate analyses also showed that being employed in a program site increased attitudinal scores toward hospice and pediatric palliative care by 0.6 points. Beyond being employed in an area city where a pediatric palliative care program operates, results also suggest that having prior training in palliative care could alter nurses' attitudes, which might subsequently lead to increased referrals and improved outcomes for children and families.     

Skin findings in palliative care patients

The prevalence of dermatologic disease and its effect on quality of life has not been well studied in patients with advanced illness. We sought to describe skin findings in inpatient palliative care patients and determine how often they are addressed by the primary or palliative care teams. We collected patient demographic and clinical data from the medical record, performed total body skin examinations, and determined how often significant cutaneous findings were documented in the chart. We also characterized skin findings as uncomfortable and treatable. Twenty palliative care patients participated in the study over a 2-month period. Common findings included skin breakdown (20/54; 37%), skin infections (14/54; 26%), inflammatory dermatoses (9/54; 17%), and skin conditions related to systemic disease (7/54; 13%) or treatment of systemic disease (4/54; 7%). Most of these conditions were not documented by primary or palliative care clinicians. Eighty percent of the patients had uncomfortable, but treatable skin conditions of which 62% (13/21) were undocumented or incorrectly documented. These limited data suggest the need for palliative care clinicians to conduct more complete skin examinations, and to improve their knowledge of common skin abnormalities in patients with serious illness. A larger scale investigation of skin disease and its effect on quality of life in the palliative care population is warranted.     

Recognizing depression in palliative care patients

Clinically significant depression is a common psychiatric disorder in patients with advanced and terminal diseases. Depression is often unrecognized and untreated and it causes major suffering to patients and families. Having adequate knowledge and skills to properly recognize depression in patients with advanced illnesses is essential for providing comprehensive end-of-life care. The objective of this paper is to review the key elements of the assessment of depression in palliative care patients. We also discuss the challenges of making the diagnosis, review the risk factors associated with depression and describe the features of the most common assessment tools that have been studied in this population. Finally, we highlight how to differentiate depression from normal grief, as the overlap between these conditions imposes a diagnostic challenge.     

Changes in medical and nursing care in cancer patients transferred from a palliative care team to a palliative care unit

The primary aim of this study was to explore the changes in medical/nursing care in patients who transferred from a palliative care team (PCT) to a palliative care unit (PCU) in the same hospital, and to explore the reasons why new or modified interventions were required. This was a retrospective study of 50 consecutive patients who were transferred from PCT to PCU in a 750-bed general hospital. A trained nurse performed a chart review and recorded the changes in 1) medical/nursing care, 2) help with decision-making within 48 hours after PCU admission, and 3) documentation of family and psycho-existential care. Group discussions among PCT and PCU staff members explored the potential reasons for the changes. Five patients were excluded due to admission periods of shorter than 48 hours. The number of new/modified medical and nursing care interventions after PCU admission averaged 1.9 ± 1.5 and 1.5 ± 1.3 per patient, respectively. The most common medical treatments were: reduction in hydration volume, dose titration of opioids, change in opioid administration device, opioid rotation, and addition of NSAIDs and steroids. The most common nursing interventions were: allowing patient to take a bath, changing mattress, use of massage, and discontinuation of bronchial suctioning. In addition, PCU staff newly coordinated opportunities to discuss preferred end-of-life care with primary caregivers in 38% of the cases, family members other than primary caregivers in 16%, and patients in 6.7%. The chart documentation of family care and psycho-existential care increased considerably after PCU admission. The chief reasons for these changes were: under-recognition of the problems and unavailability of treatments (pharmacological treatments), no intention to intervene and recommendations not followed by primary physicians (rehydration therapy), no intention to intervene (nursing care), and no intention to intervene and under-recognition of the problems (help with decision-making). These data demonstrate that many patients under PCT consultation receive new or modified interventions after PCU admission. Potentially useful strategies to strengthen the PCT interventions are: modification of intervention structure to minimize under-recognition of symptoms and decision making problems (e.g., use of standardized assessment tools, regular conferences), changes in the health care system to allow unlicensed drugs, clinical studies to clarify the benefits of artificial hydration therapy, and greater efforts to intervene in the areas of nursing care, help with decision making, family care, and psycho-existential care.     

Fatigue in patients receiving palliative care

This article discusses fatigue in patients receiving palliative care. The article initially considers the prevalence of fatigue in different groups of palliative care patients, then addresses how it manifests before reviewing how it can be assessed and managed. The focus of the article is on palliative care but it draws on, and has relevance for, chronic disease more widely.     

Knowledge and attitudes of patients with diabetes mellitus in a primary health care system

The objective of this study was to characterize patients with type 2 diabetes mellitus, according to sociodemographic and clinical variables, and to analyze scores of knowledge and attitudes regarding the disease. Participants were 79 users who received care in a primary health care service, in 2008. The Diabetes Mellitus Knowledge (DKN-A) and Attitude (ATT-19) questionnaires were used for data collection. The population was formed by adults and elderly adults, who were between 30 and 80 years old. Most were literate (96.3%); married (63.3%); female (63.3%) and classified as class-2 obesity. As to the knowledge about the disease, subjects obtained scores lower than 8, indicating unsatisfactory results on self-care. Scores obtained regarding attitudes show difficulties to cope with the disease. Results evidence the need to adopt a Diabetes Education Program at the studied unit.