Author Interviews, Depression, End of Life Care, JAMA / 28.05.2015

Katherine Ornstein, PhD MPH Assistant Professor Brookdale Department of Geriatrics and Palliative Medicine Institute for Translational Epidemiology Icahn School of Medicine at Mount Sinai One Gustave L. Levy Place, Box 1070 New York, NY 10029MedicalResearch.co Interview with: Katherine Ornstein, PhD MPH Assistant Professor Brookdale Department of Geriatrics and Palliative Medicine Institute for Translational Epidemiology Icahn School of Medicine at Mount Sinai New York, NY 10029 Medical Research: What is the background for this study? What are the main findings? Dr. Ornstein: There is an increased focus on the need to support caregivers and families, particularly at the End of Life (EOL). They play a critical role in the care process and decision making, yet this can be a very high stress role with an increased risk for negative consequences. Hospice services, which are increasing, are focused on palliative rather than curative care and include medical services, symptom management, spiritual counseling, social services and bereavement counseling delivered by an interdisciplinary team of professionals for dying patients.  An important part of the hospice service is the provision of support to families during illness and after death.  Prior research suggests that hospice (which is cost saving, has benefits to patients), may also  be beneficial to families. Yet these studies have been largely limited to patients with cancer, have failed to adequately control for differences between patients who do or do not use hospice. Overall, there was an increase in depressive symptoms after death.  However, surviving spouses of those who used hospice were more likely to have a decrease in depressive symptoms. We found that the positive benefit of hospice was much stronger when we looked at least 1 year after death. (more…)
Aging, Author Interviews, BMJ, Disability Research, End of Life Care, Geriatrics, Yale / 21.05.2015

Thomas M. Gill, M.D Humana Foundation Professor of Medicine (Geriatrics) Professor of Epidemiology (Chronic Diseases) and of Investigative Medicine Director Yale Program on Aging and Yale Center for Disability and Disabling Disorders Director, Yale Training Program in Geriatric Clinical Epidemiology and Aging-Related ResearchMedicalResearch.com Interview with: Thomas M. Gill, M.D Humana Foundation Professor of Medicine (Geriatrics) Professor of Epidemiology  and of Investigative Medicine Director Yale Program on Aging and Yale Center for Disability and Disabling Disorders Director, Yale Training Program in Geriatric Clinical Epidemiology and Aging-Related Research Medical Research: What is the background for this study? What are the main findings?h Response: Understanding the disabling process at the end of life is essential for informed decision-making among older persons, their families, and their physicians. We know from prior research that the course of disability at the end of life does not follow a predictable pattern for most older persons.  This raises the question about what is driving the development and progression of disability at the end of life. We identified six distinct trajectories of disability in the last year of life, ranging from the least disabled to most disabled.  We found that the course of disability in the last year of life closely tracked the monthly prevalence of hospitalization for each of the six trajectories. (more…)
Author Interviews, Cancer Research, End of Life Care, Surgical Research, UC Davis / 04.05.2015

Robert J Canter MD Associate Professor of Clinical Surgery Division of Surgical Oncology University of California at DavisMedicalResearch.com Interview with: Robert J Canter MD Associate Professor of Clinical Surgery Division of Surgical Oncology University of California at Davis Medical Research: What is the background for this study? Dr. Canter: Our data suggest that surgeons are improving in their ability to select patients for surgical intervention in cancer patients near their end of life. Our research suggests that surgeons may be operating on healthier patients who are anticipated to have a better recover from a palliative operation. These are patients who can perform activities of daily living without assistance, for example. Our interest in the appropriate surgical care of people with late-stage cancer grew from observing terminally ill patients whose acute problems were addressed through surgery, and who then suffered complications resulting in lengthy stays in intensive care units, and even in death. Unfortunately, it is quite common that this group of disseminated malignancy patients end up dying in the intensive care unit instead of being managed with less invasive interventions with hopes of returning home with their families, including with hospice care. (more…)
Author Interviews, End of Life Care, Heart Disease, JAMA, Kidney Disease / 27.04.2015

MedicalResearch.com Interview with: Susan P. Y. Wong, M.D. Acting Instructor & Senior Research Fellow Division of Nephrology University of Washington Medical Research: What is the background for this study? What are the main findings? Dr. Wong: There is a paucity of information on the use of cardiopulmonary resuscitation (CPR) and its outcomes among patients receiving maintenance dialysis. To address this knowledge gap, we performed a retrospective study to define contemporary trends in in-hospital CPR use and its outcomes among a nationally representative sample of 663,734 patients receiving maintenance dialysis between 2000 and 2011. We found that in-hospital CPR use among this cohort of patients was very high—nearly 20 times more common than that found in the general population. The rate of in-hospital CPR use has also been increasing among patients receiving maintenance dialysis despite evidence of poor long-term survival among these patients. Median survival after hospital discharge for members of this cohort was only 5 months, and this has not change substantially in the recent decade. We also found that a large proportion  of dialysis patients who died in hospital settings had received CPR during their terminal hospitalization. This proportion has also been steadily increasing over time, and in 2011, 1 in 5 dialysis patients who died in hospital had received CPR during their terminal hospitalization. (more…)
Author Interviews, End of Life Care, JAMA, Outcomes & Safety / 15.04.2015

Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199MedicalResearch.com Interview with: Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199 MedicalResearch: What is the background for this study? Dr. Stefan : Mortality rates for patients with pneumonia are publicly reported and are used to evaluate hospital performance. The rates are calculated using Medicare administrative claims data which provide limited insight into severity of illness and comorbidities that may be associated with death. The mortality measure does not take into consideration advance directives or changes in goals of care preferences during hospitalization. MedicalResearch: What are the main findings? Dr. Stefan : In this retrospective chart review of 202 adults who died with a principal diagnosis of pneumonia between January 2008 and December 2012 in 3 hospitals in MA, we assessed the proportion of patients for whom pneumonia was determined to play a major or a minor role in the patient death. Pneumonia was considered a minor cause if the patient had advanced life threatening illnesses and this was found in 82% of the deaths. More than half of the patients were DNR at admission to the hospital. The majority of patients who died were frail elderly with life-threatening conditions who decided to forgo aggressive care at some point during their admission. Only a small fraction of deaths in the pneumonia mortality measure were the direct result of pneumonia. (more…)
Author Interviews, End of Life Care / 06.04.2015

Prof. Chetna Malhotra M.B.B.S., M.D. M.P.H. Lien Centre for Palliative Care Duke-NUS Graduate Medical School Singapore, SingaporeMedicalResearch.com Interview with: Prof. Chetna Malhotra M.B.B.S., M.D. M.P.H. Lien Centre for Palliative Care Duke-NUS Graduate Medical School Singapore, Singapore Medical Research: What is the background for this study? What are the main findings? Dr. Malhotra: Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life- extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. In this study, we aim to understand the relative value that advanced cancer patients and their caregivers place on various aspects of end-of-life care. We conducted a cross-sectional survey of 211 patients with stage IV cancer and their primary informal caregivers.  Participants were asked to choose their most-preferred end-of-life scenarios out of a series of options that varied along key dimensions, including years of life remaining, degree of pain experienced, place of death, level of burden on caregivers, quality of healthcare experience, cost, and source of payment (cash, Medisave, or family members’ cash or  Medisave). Using the results, we quantified patients and caregivers willingness to pay to improve their end of life experience. We found that the patients’ willingness to pay to extend their life by one year was valued at S$18,570, which is lower than their willingness to pay to avoid severe pain (S$22,199), or to die at home (S$31,256). Caregivers had a three-fold greater willingness to pay than patients to extend life by one year and for most of the other features considered. These results suggest that health insurers and physicians may be putting too much emphasis on life extending treatments for these patients. Further, there is a need to elicit patient preferences during treatment decision making as opposed to just relying on caregiver input. (more…)
Author Interviews, BMJ, End of Life Care, Heart Disease / 04.03.2015

MedicalResearch.com Interview with: Prof. Dr. med. Paul Erne AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute University of Zurich Department of Cardiology Clinic St. Anna, Lucerne and University Hospital Zurich Zurich, SwitzerlandProf. Dr. med. Paul Erne AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute University of Zurich Department of Cardiology Clinic St. Anna, Lucerne and University Hospital Zurich Zurich, Switzerland MedicalResearch: What is the background for this study? What are the main findings? Prof. Erne: Very little is known on this important subgroup of patients with Acute Coronary Syndrome (ACS) at admission who for various reasons receive restricted or palliative treatment only. Reasons for withholding comprehensive and/or invasive therapy may be the very limited life expectancy, advanced age or severe comorbidities. These patients are not represented in prospective trials and often not included in outcome statistics and registries. This study provides evidence that the population which received palliative therapy is older and sicker when compared to patients who underwent conservative or reperfusion treatment. However, this study shows that these decisions are very individually addressed. Acute Coronary Syndrome patients treated palliatively were older, sicker, with more heart failure at admission and very high in-hospital mortality. Changes of treatment decisions over time and the proportion of patients surviving 1 year suggest in part non homogenous and potentially questionable decision criteria. While refraining from more active therapy may be the most humane and appropriate approach in many patients, in others it represents under treatment. (more…)
Author Interviews, End of Life Care / 18.02.2015

Eva E. Bolt MD Physician researcher Dept. Public and Occupational Health EMGO+ Institute for Health and Care Research (VU University Medical Center) Medical Faculty Amsterdam, The NetherlandsMedicalResearch.com Interview with: Eva E. Bolt MD Physician researcher Dept. Public and Occupational Health EMGO+ Institute for Health and Care Research (VU University Medical Center) Medical Faculty Amsterdam, The Netherlands Medical Research: What is the background for this study? What are the main findings? Dr. Bolt: Three-quarter of all Dutch physicians have ever been asked by a patient to perform euthanasia. Each request for euthanasia calls for careful deliberation. Firstly, the physician needs to judge whether euthanasia would be possible within the limits of the law. Above that, a physician needs to decide whether performing euthanasia is in line with his personal believes and values. This study shows that cause of suffering is an important factor in this decision. In the Netherlands, the euthanasia law gives physicians the possibility of performing euthanasia, if they adhere to strict rules. The euthanasia law is not restricted to certain diseases. However, this study shows that the attitude of physicians towards performing euthanasia varies by condition. Most Dutch physicians would consider granting a request for euthanasia in case of cancer (85%) or another severe physical disease (82%). In contrast, only four out of ten physicians would consider granting a request for euthanasia in case of early-stage dementia. One in three would consider it in case of advanced dementia or psychiatric disease, and one in four in case of a person who is tired of living without suffering from a severe disease. (more…)
Annals Internal Medicine, Author Interviews, End of Life Care / 07.02.2015

Adam E. Singer, MPhil, Pardee RAND Graduate School, RAND Corporation Santa Monica, CAMedicalResearch.com Interview with: Adam E. Singer, MPhil Pardee RAND Graduate School, RAND Corporation Santa Monica, CA MedicalResearch: What is the background for this study? What are the main findings? Response: In 1997, the Institute of Medicine (IOM) released a seminal report on the state of end-of-life care in the US that called for major changes in the organization and delivery of end-of-life care. Many of the IOM’s indictments have ostensibly been addressed since that time through the expansion of palliative care and hospice, along with a greater focus on symptom management in both policy and practice. This study was designed to ask whether end-of-life symptoms have become less prevalent from 1998 to 2010 for the population as a whole and also for subgroups that died suddenly or had cancer, congestive heart failure (CHF), chronic lung disease, or frailty. The study found that many alarming symptoms were common in the last year of life and affected more people from 1998 to 2010. For example, in the whole population, pain affected 54% in 1998 and 61% in 2010 (a 12% increase). Depression affected 45% in 1998 and 57% in 2010 (a 27% increase). Periodic confusion affected 41% in 1998 and 54% in 2010 (a 31% increase). Depression and periodic confusion also became more prevalent in subgroups with CHF and/or chronic lung disease and frailty. In addition, nearly all other symptoms in the whole population and in each of the subgroups trended toward increases in prevalence from 1998 to 2010, although most of these trends did not reach statistical significance. The one exception is that there were no significant changes in the subgroup with cancer. (more…)
Author Interviews, End of Life Care, JAMA / 12.01.2015

MedicalResearch.com Interview with: Younsuck Koh Professor of Medicine Professor of Medical Humanities and Social Sciences Chairman, the Organizing Committee of the 12th World Federation of Societies of Intensive and Critical Care Medicine Congress in Seoul Department of Pulmonary and Critical Care Medicine Asan Medical Center, Univ. of Ulsan College of Medicine Seoul, Korea and Jason Phua MBBS, FRCP National University Hospital, Singapore AVF Chairperson. Senior Consultant & Head Division of Respiratory & Critical Care Medicine Medical Research: What is the background for this study? What are the main findings? Response: Provision of humane end-of-life and palliative care for dying patients and their families must remain a focus in today’s intensive care units, which continue to see technological advancements in the forms of life-sustaining measures available. End-of-life care decisions are heavily dependent on the medical, ethical, social, and cultural context. Asia, which accounts for at least half of all patients with critical illness, mechanical ventilation, and intensive care unit deaths internationally, has diverse socioeconomic conditions, cultures, and religions. Therefore, it is likely that substantial difference in the way physicians approach end-of-life care exist between Asia and the West, and among Asian countries and regions themselves. However, prior to our study, little data existed on the end-of-life care practices in this region. We found that even as end-of-life care practices in intensive care units vary significantly across Asian countries and regions, physicians in Asia generally seem less likely to limit life-sustaining treatments than their Western counterparts. Implementation of do-not-resuscitate orders are affected by multiple factors related to country or region, including economic, cultural, religious, and legal differences, as well as personal attitudes. (more…)
Author Interviews, End of Life Care, Pain Research / 18.12.2014

MedicalResearch.com Interview with: Melissa Garrido, PhD Research Health Science Specialist GRECC, James J Peters VA Medical Center, Bronx, NY Assistant Professor Brookdale Department of Geriatrics & Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY and Holly G. Prigerson, PhD Center for Research on End of Life Care Weill Cornell Medical College New York, NY 10065 Medical Research: What is the background for this study? What are the main findings? Response: Recent proposals in Congress encourage patients to engage in advance care planning and to complete advance directives. That is, patients are encouraged to have conversations about end-of-life care preferences and to document these preferences in writing (through living wills or medical orders such as do not resuscitate (DNR) orders) or to designate a durable power of attorney who can honor their preferences. The goal of advance care planning is to ensure that seriously ill patients receive care that matches their values. In this study, we used data from a prospective study of patients with advanced cancer and their caregivers to examine whether living wills, durable powers of attorney, and DNR orders were associated with better quality of life and lower estimated costs of care in the week before death. We examined these relationships among patients who did and did not express preferences for “heroic” end-of-life care (everything possible to remain alive). Medical Research: What are the main findings? Response: DNR orders were associated with better quality of life in the week before death among the entire sample. If patients have DNR orders completed, they are likely to have a better quality of life/quality of death than if they do not complete a medical order like this. We did not find any evidence of a relationship between DNR orders and costs of care, nor did we find evidence of relationships among living wills or durable powers of attorney, quality of life, and costs of care. There was no evidence that relationships among advance care planning and outcomes differed by patient preferences for heroic care. (more…)
Author Interviews, Cancer Research, End of Life Care, JAMA / 12.11.2014

Ziad Obermeyer, MD, MPhil Emergency Medicine, Brigham & Women's Hospital Assistant Professor, Harvard Medical SchoolMedicalResearch.com Interview with: Ziad Obermeyer, MD, MPhil Emergency Medicine, Brigham & Women's Hospital Assistant Professor, Harvard Medical School Medical Research: What is the background for this study? What are the main findings? Dr. Obermeyer: More patients with cancer use hospice today than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. We examined how hospice affects health care utilization and costs and found that, in a sample of elderly Medicare patients with advanced cancer, hospice care was associated with significantly lower rates of both health care utilization and total costs during the last year of life. Patients who did not enroll in hospice had considerably more aggressive care in their last year of life—most of it related to acute complications like infections and organ failure, and not directly related to cancer-directed treatment. Hospice and non-hospice patients had similar patterns of health care utilization until the week of hospice enrollment, when care began to diverge. Ultimately, non-hospice patients were five times more likely to die in hospitals and nursing homes. These differences in care contributed to a statistically-significant difference in total costs of $8,697 over the last year of life ($71,517 for non-hospice and $62,819 for hospice). (more…)
Author Interviews, End of Life Care, Erasmus / 15.10.2014

F.E. (Erica) Witkamp RN MSc Senior lecturer University of Applied Sciences Erasmus MC and Erasmus MC Cancer Institute Rotterdam, The Netherlands.MedicalResearch.com Interview with: F.E. (Erica) Witkamp RN MSc Senior lecturer University of Applied Sciences Erasmus MC and Erasmus MC Cancer Institute Rotterdam, The Netherlands. Medical Research: What are the main findings of the study? Response: We investigated the experiences of 249 bereaved relatives (response 51%) of patients who had died in the hospital, after a hospitalization of at least six hours. The main outcome measure was their global score of the quality of dying (QOD) on a 0-10 scale, with zero being “very poor” and ten “almost perfect”. Further, we assessed multiple experiences in the last days of life, such as symptom burden, preparedness for life closure, awareness of impending death, and care in the last days of life. We analyzed which of these factors was related to the quality of dying score, and subsequently whether the related factors represented specific domains of the dying phase. Relatives rated the overall score of QOD on average at 6.3 (sd 2.7) with a range from 0-10. During the last day(s) of life, 26% of the patients, and 49% of the relatives had been fully aware of imminent death. In the end 39% of the patients and 50% of the relatives had said goodbye; 77% of the patients had died in the presence of a relative. According to relatives patients had suffered moderately to severely from on average 7 out of 22 symptoms. In 53% relatives reported that in the last 24 hours symptoms had sufficiently been alleviated; efforts to control symptoms had been sufficient in 75%. In 64% relatives had been informed by the physician about the imminence of death, and in 70% they were satisfied about their involvement in decision making. In 55% relatives had experienced sufficient attention to individual preferences and wishes, and in 70% hospital facilities had been sufficient. Patients had been sufficiently affirmed as a person in 63%. (more…)
Author Interviews, Cancer, Cancer Research, End of Life Care / 09.09.2014

MedicalResearch.com Interview with: Karin Jors MA Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany Medical Research: What are the main findings of the study? Answer: The findings of our study shed light on the current circumstances for dying in cancer centers. Physicians and nurses in our study reported that they rarely have enough time to care for dying patients. In addition, only a minority of staff members felt that they had been well-prepared during their training to care for dying patients and their families. Overall, only 56% of participants indicated that it is usually possible for patients to die in dignity on their ward. This is likely the result of various factors such as: inadequate rooms for dying patients and their families (i.e. shared rooms), poor communication with patients regarding burdensome treatments, an overuse of life-prolonging measures, etc. Striking differences were found between the responses of palliative care staff and staff from other wards (e.g. general care, oncology, intensive care). For example, palliative care staff reported that they usually have enough time to care for dying patients. In addition, 95% of palliative care staff indicated that it is usually possible for patients to die in dignity on their ward. Overall, nurses perceived the situation for dying patients more negatively than physicians. Whereas 72% of physicians reported that patients can usually die a dignified death on their ward, only 52% of nurses shared this opinion. Although only slightly more than half of participants believed that patients can usually die in dignity on their ward, this is a considerable improvement to the situation 25 years ago. In a similar study published in 1989, researchers found that 72% of physicians and nurses experienced the situation for patients dying on their hospital ward as undignified. (more…)
Author Interviews, Depression, End of Life Care / 04.09.2014

MedicalResearch.com Interview with: Nenette M. Jessup MPH, CCRP Research Associate/Project Manager TASK II Indiana University School of Nursing Indianapolis, IN 46202 Medical Research: What are the main findings of the study? Dr. Jessup: Similar to others, we found that females and non-African American caregivers experienced more depressive symptoms and females perceived greater task difficulty. Because female caregivers comprise the largest group of caregivers in the United States, the consistency of this finding has implications for continued social policy efforts to improve their plight. However, our results also suggested an interaction effect between race and type of relationship, with African American spouses experiencing the most difficulty with tasks of caregiving. Inconsistencies in the existing literature about this finding signal the need for a greater understanding of group differences. Individualized interventions may also be of benefit for stroke caregivers. (more…)
Author Interviews, End of Life Care, Race/Ethnic Diversity / 25.08.2014

Holly G. Prigerson, Ph.D. Irving Sherwood Wright Professor in Geriatrics Professor of Sociology in Medicine Director, Center for Research on End of Life Care Weill Cornell Medical College 1404 Baker Pavilion, New York Presbyterian Hospital New York City, New York 10065MedicalResearch.com Interview with: Holly G. Prigerson, Ph.D. Irving Sherwood Wright Professor in Geriatrics Professor of Sociology in Medicine Director, Center for Research on End of Life Care Weill Cornell Medical College New York Presbyterian Hospital  New York City, New York 10065 Medical Research: What are the main findings of the study? Dr. Prigerson: That there are strikingly different preferences for end-of-life care based on a patient's race/ethnicity and in rates of do not resuscitate order completion.  Regardless of what those preferences are, however, they significantly influence the likelihood of completing a do not resuscitate order (dnr) across racial/ethnic groups. (more…)
Author Interviews, BMJ, End of Life Care / 21.08.2014

MedicalResearch.com Interview with: Dr. Julian Mausbach RA Geschäftsführer Kompetenzzentrum Medizin - Ethik - Recht Helvetiae Zürich, Switzerland Medical Research: What are the main findings of the study? Answer: 611 cases of suicide tourism were found in the canton of Zurich between 2008 and 2012. More than half of the suicide tourists were women with a median age of 69 years. After an initial decrease in 2009, cases of suicide tourism increased from then on onwards and doubled in 2012. The underlying diseases varied considerably. Main reasons for the assisted suicide were neurological diseases, followed by cancer, rheumatic diseases. Approximately one third of the study population had more than one disease. (more…)
Author Interviews, BMJ, End of Life Care / 15.07.2014

Dr. Kirsty Boyd Programme theme head (Clinical Communication) Honorary Clinical Senior Lecturer Primary Palliative Care Research Group Division of Community Health Sciences: General Practice University of EdinburghMedicalResearch.com Interview with: Dr. Kirsty Boyd Programme theme head (Clinical Communication) Honorary Clinical Senior Lecturer Primary Palliative Care Research Group Division of Community Health Sciences: General Practice University of Edinburgh Medical Research: What do we know already about people with ‘multimorbidity’? Dr. Boyd: We know that an increasing number of patients have multiple life-limiting illnesses or progressively deteriorating health due to several long term conditions or general frailty. Caring for them well poses major challenges and they are often hospitalised in the last year of life. They do not fit well into illness and healthcare models that focus on single conditions. Understanding the experiences of patients and their family caregivers is vital to inform improvements in best supportive care and palliative care. We wanted to build on care models for integrated care of people with long term conditions and consider the needs of those at risk of dying with multiple conditions in more detail. (more…)
Author Interviews, Cancer Research, End of Life Care / 20.06.2014

Daniel Rocke, MD Medical School University of Michigan Medical School Ann Arbor, 2009.MedicalResearch.com Interview with Daniel Rocke, MD Duke Medicine Department Otolaryngology MedicalResearch: What are the main findings of the study? Dr. Rocke: I think the main point is that, to quote the paper, "end-of-life decision making by patients with cancer and their caregivers is significantly affected by their preference for quality of life or quantity of life, but OHNS physicians’ decision making is not." This is important because physicians counseling patients making end-of-life decisions are coming at these decisions from a different perspective that may not line up with their patients. If physicians recognize this, I think that these end-of-life discussions can be more productive (more…)
Author Interviews, BMJ, End of Life Care / 12.06.2014

MedicalResearch.com: Interview with: Dr. Hsien Seow PhD Cancer Care Ontario Research Chair in Health Services Research Asst Professor, Dept of Oncology, McMaster University Hamilton, OntarioDr. Hsien Seow PhD Cancer Care Ontario Research Chair in Health Services Research Asst Professor, Dept of Oncology, McMaster University Hamilton, Ontario   MedicalResearch: Why did you conduct this study? Dr. Seow: While palliative care has gained recognition as a service that can improve patient outcomes and reduce health care costs at the end of life, especially in hospitals and hospices, much less attention has focused on providing inter-disciplinary palliative care in the community and home. There have been several randomized trials that showed mixed evidence that inter-disciplinary teams of specialist palliative care providers can reduce acute care utilization in the community; however team size and team composition varied in prior trials. This variation has not been researched as a cause for the mixed outcomes. (more…)
Author Interviews, End of Life Care, Heart Disease / 21.05.2014

MedicalResearch.com Interview with: Colleen K. McIlvennan, DNP, ANP Assistant Professor of Medicine University of Colorado, Division of Cardiology                             Section of Advanced Heart Failure and TransplantationMedicalResearch.com Interview with: Colleen K. McIlvennan, DNP, ANP Assistant Professor of Medicine University of Colorado, Division of Cardiology Section of Advanced Heart Failure and Transplantation   MedicalResearch: What are the main findings of the study? Answer: We interviewed 22 patients who were offered destination therapy left ventricular assist devices (DT LVAD), 15 with DT LVADs and 7 who declined. We found a strong dichotomy between decision processes with some patients (11 accepters) being automatic and others (3 accepters, 7 decliners) being reflective in their approach to decision making. The automatic group was characterized by a fear of dying and an overriding desire to live as long as possible: [LVAD] was the only option I had…that or push up daisies…so I automatically took this. In contrast, the reflective group went through a reasoned process of weighing risks, benefits, and burdens: There are worse things than death. Irrespective of approach, most patients experienced the DT LVAD decision as a highly emotional process and many sought support from their families or spiritually. (more…)
Author Interviews, BMJ, Cancer Research, Chemotherapy, End of Life Care / 05.03.2014

Holly G. Prigerson, Ph.D. Irving Sherwood Wright Professor in Geriatrics Professor of Sociology in Medicine Co-Director, Center for End-of-Life Research Weill Cornell Medical College New York Presbyterian Hospital New York City, New York 10065MedicalResearch.com Interview with: Holly G. Prigerson, Ph.D. Irving Sherwood Wright Professor in Geriatrics Professor of Sociology in Medicine Co-Director, Center for End-of-Life Research Weill Cornell Medical College New York Presbyterian Hospital New York City, New York 10065 MedicalResearch.com: What are the main findings of the study? Dr. Prigerson: The main outcome of the research was end-of-life treatment and location of death with secondary outcomes being length of survival, late hospice referrals and attainment of preferred place of death. We found that 56 percent of patients receiving palliative chemotherapy in their final months.  Patients treated with palliative chemotherapy were five to 10 times more likely to receive intensive medical care and to die in an intensive care unit (ICU). Fewer than half died at home as compared with two-thirds of patients with metastatic cancer not treated with palliative chemotherapy. More specifically, we found that palliative chemotherapy was associated with:
  • Increased use of CPR and mechanical ventilation: 14% versus 2%
  • Late hospice referral: 54% versus 37%
  • Death in an ICU: 11% versus 2%
  • Death away from home: 47% versus 66%
  • Death away from their preferred place: 65% versus 80%
Survival did not differ significantly between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11, 95% CI 0.90-1.38). Additionally, patients receiving palliative chemotherapy were less likely to acknowledge their illness as terminal (35% versus 49%, P=0.04), to have discussed end-of-life wishes with a physician (37% versus 48%, P=0.03), and to have completed a do-not-resuscitate order (36% versus 49%, P<0.05). (more…)
Author Interviews, End of Life Care, JAMA / 17.12.2013

MedicalResearch.com Interview with: Garrett M. Chinn, MD, MS Division of General Medicine, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston MedicalResearch.com: What are the main findings of this study: Dr. Chinn:  Despite the desire of most Americans facing terminal illness to spend their remaining time at home, only 24% of those aged 65 and older do so. Many spend their final days in an institutional setting such as an acute care hospital, often receiving aggressive care. In the case of patients facing stage 4 lung cancer, many who would prefer to emphasize pain relief over extending life report not having discussed hospice with a physician. More than 25% indicate that they had not addressed advanced care directives such as do-not-resuscitate orders with their doctors but wanted to do so. This tells us that patients wish to better understand their illness and prognosis and might be interested in learning about hospice. And although the general trend for hospice utilization has increased over the past decade, a high percentage of hospice enrollment occurs quite late in the course of illness, often during an acute hospitalization. (more…)
Author Interviews, Depression, Education, End of Life Care, JAMA, Stanford / 06.12.2013

J. Randall Curtis, MD, MPH Professor of Medicine Director, UW Palliative Care Center of Excellence Section Head, Pulmonary and Critical Care Medicine, Harborview Medical CenterA. Bruce Montgomery, M.D. – American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine University of Washington, Seattle, WA 98104MedicalResearch.com Interview with: J. Randall Curtis, MD, MPH Professor of Medicine Director, UW Palliative Care Center of Excellence Section Head, Pulmonary and Critical Care Medicine, Harborview Medical CenterA. Bruce Montgomery, M.D. – American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA 98104 MedicalResearch.com: What are the main findings of the study? Dr. Curtis: We examined the effect of a communication-skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes.  The study was funded by the National Institutes of Nursing Research of the National Institutes of Heatlh.  We conducted a randomized trial with 391 internal medicine and 81 nurse practitioner trainees at two universities.  Participants were randomized to either an 8-session simulation-based, communication-skills intervention or to usual education.  We collected outcome data from a large number of patients with life-limiting illness and their families, including 1866 patient ratings and 936 family ratings.  The primary outcome was patient-reported quality of communication and, overall, this outcome did not change with the intervention.  However, when we restricted our analyses to only patients who reported their own health status as poor, the intervention was associated with increased communication ratings. Much to our surprise, the intervention was associated with a small but significant increase in depression scores among post-intervention patients.  Overall, this study demonstrates that among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education improved communication skills acquisition, but did not improve quality of communication about end-of-life care for all patients.  However, the intervention was associated with improved patient ratings of communication for the sickest patients. Furthermore, the intervention was associated with a small increase in patients’ depressive symptoms, and this appeared most marked among patients of the first-year residents. (more…)