Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure‐orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.     

Palliative care for people with COPD: we need to meet the challenge

The need to extend the palliative care approach to people dying with a wide range of chronic diseases is increasingly recognised. Whilst of relevance internationally, this topic is particularly timely in the UK as the General Medical Services contract will reward practices that create a register of patients "in need of palliative/supportive care". Difficulty predicting prognosis can lead to uncertainty about which patients with COPD to include in a register, potentially reducing the impact of this initiative. In this Discussion paper we highlight this challenge, and offer some practical strategies to help clinicians recognise these patients.     

The geriatric patient: Use of acute geriatrics units in the emergency care of elderly patients in France

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR) = 1.79 (1.38-2.32) (95% confidence interval = 95% CI); “failure to thrive” syndrome OR = 1.54 (1.01-2.35), depression: OR = 1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR = 1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the “geriatrics patient” is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.     

社区家庭照护患者的老年综合征研究

目的研究社区家庭病床患者老年综合征患病率。方法采用老年综合评估和常规的医学评估两种方法对60名65岁以上患有多种慢性疾病的社区家庭病床的老年患者进行老年综合征的患病率评估。结果60名老年患者,年龄67～94岁,平均年龄（79．84-2．1）岁,其中男28人,女32人,患有已明确诊断的慢性病有（6．6±2.0）种。老年综合评估为认知功能减退19例（31．7％）,抑郁症状10例患者（16．6％）,生活活动功能下降22例（36．7％）,在最近1年跌倒16例（26．7％）,尿失禁17例（28．3％）。而常规的医学评估,有明确的认知障碍者2例（3．3％）,抑郁症1例（1．7％）活动功能下降8例（13．3％）,跌倒2例（3．3％）,尿失禁3例（5％）,经过配对卡方检验,与老年综合评估方法比较,P值均〈0．05,差异有统计学意义。结论老年综合征在社区家庭照护老年患者中有较高的患病率,常规的医学评估容易忽视这些症状,推荐常规使用老年综合评估的方法进行检查。     

Palliative care and hematologic oncology: The promise of collaboration

Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.     

人口老龄化对我国健康保健服务体系的挑战与对策

人口老龄化对健康保健服务体系的挑战主要体现医疗、康复和照护需求。积极应对人口老龄化,实现健康老龄化,亟须加强医养结合的实践探索和政策设计,建设医疗、照护与环境相结合的公共卫生服务体系,加强老年医学专业人才培训管理体系的建设和建立多层次医疗保障体系等方面。基于我国人口老龄化的现状和发展趋势,分析其对我国健康保健服务体系的影响,提出符合我国国情的对策与建议。     

Palliative care in heart failure guidelines: A comparison of the 2021 ESC and the 2022 AHA/ACC/HFSA guidelines on heart failure

The role of palliative care for patients with heart failure (HF) is discussed in both most recent HF guidelines, the 2021 ESC guideline and the 2022 AHA/ACC/HFSA guideline. This review compares the definitions, concepts and specific recommendations regarding palliative care for patients with HF in these two guidelines. Both HF guidelines define palliative care as a multidisciplinary approach aimed at alleviating physical, psychological and spiritual distress of patients and caregivers. Both agree emphatically on the importance of palliative care across all stages of HF with integration early in the illness trajectory. Also, the guidelines concur that palliative care should include symptom management, communication about prognosis and life-sustaining therapies, as well as advance care planning. Despite this consensus, only the AHA/ACC/HFSA guideline gives official recommendations on the provision of palliative care. Moreover, the AHA/ACC/HFSA guideline advocates for a needs-based approach to palliative care allocation while the ESC guideline ties palliative care closely to advanced HF and end-of-life care. The ESC guideline highlights the need for regular symptom assessment and provides detailed guidance on symptom management. The AHA/ACC/HFSA guideline elaborates further on shared decision-making, caregiver and bereavement support, as well as hospice care, and distinguishes between primary palliative care (provided by all clinicians) and secondary (specialty-level) palliative care. Although there is strong agreement on the importance and components of palliative care for patients with HF, there are nuanced differences between the two HF guidelines. Most notably, only the AHA/ACC/HFSA guideline issues recommendations for the provision of palliative care.     

The impact of geriatric consultation on the care of the elders in community clinics

The aim of this retrospective study was to describe and evaluate the impact of a new model used in caring for the elders in the community, based on geriatrician consultation, initiated by their general physician (GP) and conducted by both in five urban primary care clinics. Five hundred and forty-two elderly patients were referred to a geriatric consultant during a 41-month period. The patients’ demographic, functional, cognitive medical status, reasons for referral and recommendations were recorded. Implementation by the GP of the geriatrician's recommendations was analyzed with the number of visits during the 6-month follow up. Patients were referred mainly for affective, cognitive, medical problems, functional decline and gait disturbances in 39.7%, 30.4%, 24.4%, 18.6% and 12.7% of cases, respectively. The referrals to the geriatrician increased from 133 in 2004 to 207 in 2006 (p = 0.01), while the visits to the GP decreased from 10.9 to 10.2 during 6-month period following the geriatric consultation (p < 0.01). No decline was found in the other elderly patients. In most cases, the GP implemented the geriatrician's advice (p < 0.01). Geriatrician consultations and recommendations in the primary care clinic were well accepted by the GP, thereby reducing the number of visits.     

Prevalence of hypomagnesemia (HM) in a geriatric long-term care (LTC) setting

Electrolyte abnormalities are frequently observed in elderly long-term care (LTC) patients. Magnesium is a trace mineral, but is the second most abundant intracellular cation and the fourth most abundant cation in the body. This was a cross-sectional study to assess the prevalence of hypomagnesemia (HM) in non-selected elderly LTC patients. A total of 159 patients aged 65 years and older were included in the study. The attributes and variables related to the patients’ hospital course were used to compare the two groups. We used univariate and multivariate analyses to correlate magnesium levels with demographic, clinical factors and laboratory data. HM was found in 36% of the patients, of whom 35% presented with moderate HM (0.8-0.9 μequiv./l) and 18% with severe HM (≤0.7 μequiv./l). Patients with HM had a higher number of comorbid diseases per patient (p = 0.038), low body mass index (BMI) (p = 0.044) and more of them presented with laboratory markers of malnutrition, such as low total cholesterol (TC) and serum albumin (SA) levels. Coexistence with other electrolyte abnormalities was higher among patients with HM than without (p = 0.006), predominantly hypocalcemia and hypokalemia (p = 0.023 and 0.032, respectively). Using regression analysis, independent variables significantly associated with serum magnesium levels were serum albumin, calcium, potassium, urea levels, chronic renal failure (CRF), chronic heart failure (CHF), diabetes mellitus (DM) and diuretic drugs (R² = 0.877). Both early (up to 30 days) and late rate of death were higher in patients with HM. The incidence of HM in LTC elderly patients is high and multifactorial. Understanding the causes of HM, correction of magnesium level, and definitive and effective treatment of the cause leading to HM is important to improve patient prognosis.     

Sarcopenia,physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit

Sarcopenia is the loss of muscle mass and strength, which in the elderly can result in disability and affect functional outcomes after hospitalization. The aim of this study was to evaluate the functional outcomes and mortality during hospitalization and at three months post-discharge, according to the presence of sarcopenia.     

Teaching of geriatric health in India: Mapping the terrain

ABSTRACT

India is currently undergoing a rapid demographic transition along with a dramatic upsurge in the number of elderly adults. Creating a cadre of specialized health care professionals in geriatric medicine is clearly vital to address the health care needs of this growing population. The authors undertook a mapping of the available academic programs in geriatric health in India and examined their content, duration, architecture, and student intake. A total of 20 programs were identified in geriatric health, thus highlighting a paucity of training options in this field. Compared to Western countries, relatively few programs are offered in clinical and public health geriatrics in India. This is further compounded by an insignificant thrust of geriatrics in undergraduate health professional curricula. Our results underscore the need for a national-level curricular initiative to strengthen and mainstream the teaching of geriatric health in the country. Alternative educational strategies such as blended learning and interprofessional education should be explored to enhance geriatric health workforce competence.     

General health perception,depression and quality of life in geriatric grandmothers providing care for grandchildren

Aim/backgroundTo investigate levels of depression, quality of life, general health perception, and factors affecting these in grandmothers providing care for their grandchildren.Material/methodOne hundred two family physicians from four cities (Samsun, Amasya, Canakkale, and Izmir) in Turkey investigated 2859 women older than 65 years on their patient lists. Of these, 282 (9.8%) had spent at least 50 h caring for their grandchildren in the previous three months, and these were selected as the study group, while the remaining 2563 (89.6%) were enrolled as the control group. After all participants’ demographic variables had been investigated, they completed the Beck Depression Inventory (BDI), Self-Function 12 (Mental and physical component score) (SF-12), and the Visual Analog Scale of EQ-5D (VAS). The participants in the study group also completed a questionnaire investigating features of their grandchild care.ResultsThe study group (with the exception of custodial grandmothers) scored better on the SF-12 (PSC = 50.60 ± 6.96 vs 48.24 ± 8.12), (MCS = 49.70 ± 7.77 vs 45.48 ± 7.61), VAS (60.44 ± 23.5 vs 54.16 ± 19.5), and BDI (13.97 ± 0.3 vs 19.49 ± 0.2) compared to the control group (p < 0.0001 for all). Age, monthly income, mean length of education, duration of care, mean hours spent caregiving per week, being a custodial grandmother, presence of more than one chronic disease, and caring for more than one grandchild at a time were identified as factors affecting SF-12, VAS and BID in the study group.ConclusionGrandchild care positively affected the grandmothers’ quality of life, depression levels, and general health perception, with the exception of custodial grandmothers.     

Association of palliative care management and survival after chemotherapy discontinuation in patients with advanced pancreatic adenocarcinoma: A retrospective single-centre observational study

BackgroundPalliative care (PC) is integrated into standard oncology care. However, its clinical impact at the end of life remains unclear in pancreatic adenocarcinoma (PA). We aimed to describe the end-of-life care pathway and to assess whether PC referral influences survival after chemotherapy discontinuation (CD) among advanced PA patients.MethodsThis retrospective single-centre observational study was conducted among deceased patients with advanced PA who had received chemotherapy between January 1, 2016, and December 31, 2021. Baseline characteristics, the timing of PC referral and events after CD were collected. The primary outcome was time from CD to death.ResultsAmong the 148 included patients, 53.4% (n = 79) received PC, mostly late after the CD (n = 133, 89.9%), 16.9% (n = 25) received chemotherapy in the last 14 days of life and 75.6% died at the hospital. None received PC in the 8 weeks following the diagnosis. PC referral significantly increased PC department admissions (p < 0.001) and decreased medical unit admissions (p < 0.001). The median survival after the CD was 35 days (IQR: 19–64.5). PC referral was associated with increased survival after CD (HR: 0.65 [0.47–0.90], p = 0.010, Cox) and after adjusting (HR: 0.65 [0.42–0.99], p = 0.045, Cox).ConclusionThe study suggests that PC may be associated with longer survival after CD in advanced PA patients. However, PC is underused, and patients are referred late in their care pathway.