Symptom burden and palliative care needs of breathless patients with severe COPD are considerable and as high as among patients with advanced primary and secondary lung cancer although patients with COPD have a longer survival.
Breathlessness is a distressing symptom in advanced disease. Little is known about the trajectories of this symptom over time and towards death. This study aimed to describe and compare the summary and individual trajectories of breathlessness and overall symptom burden over time and towards the end of life following patients with advanced cancer or severe chronic obstructive pulmonary disease (COPD) in inpatient and outpatient health care settings in Germany. The modified Borg Scale, Memorial Symptom Assessment Scale Short Form and Palliative Outcome Scale were used as outcome measures. Data were collected at baseline and then monthly over six months or until death. Forty-nine cancer and 60 COPD patients were included. Both groups had similar demographics. Thirty out of the 49 cancer and 6/60 COPD patients died, 7/49 cancer and 20/60 COPD patients dropped out due to physical deterioration or questionnaire fatigue. In cancer patients, breathlessness increased towards death. In COPD patients, breathlessness increased over time. Twenty-one cancer and 43 COPD patients provided data for individual breathlessness trajectories. These revealed wide individual variations with four different patterns: fluctuation, increasing, stable and decreasing breathlessness. Symptom trajectories on the population level reflecting the whole group mask individual variation, which is reflected in distinct symptom trajectories with different patterns.
Outcome measurement is becoming increasingly important in palliative care both in research as well as clinical care. Regular ongoing assessments in palliative care clinical practice have the potential to enable monitoring of the patient's situation, assess the effectiveness of interventions, assess symptoms accurately and focus on patients' priorities. Implementing routine outcome measurement into clinical practice remains a challenge. Therefore, the aim of this article is to describe the process of implementing routine outcome measurement into daily clinical work in a university palliative care unit. According to the recommendations of Antunes, the following steps were used to implement routine outcome measurement in clinical care in a university palliative care unit. (I) Selection of outcomes of interest by the clinical leads and head of department: most prevalent symptoms; psychological, practical and spiritual concerns, functional status, carer burden; (II) selection of outcome measures: Integrated Palliative Care Outcome Scale (IPOS), phase of illness, Australian Karnofsky Performance Status; (III) educational component about the measure and how to use results: team meetings and team retreat with introduction of outcome measurement in palliative care, chosen measures and role plays with use of measures; (IV) selection of responsible consultant on the ward as coordinator and facilitator for outcome measurement; (V) who applies the measure and its periodicity. Implementation of outcome measurement in clinical routine is feasible following a structured process. Nevertheless, it is a time consuming and long-lasting process which needs continuous attention. However, the benefits outweigh the burden of implementation and it is a task worthwhile undertaking.
Bei der COVID-19-Pandemie handelt es sich um eine sich sehr dynamisch entwickelnde Situation, die die palliativmedizinische Versorgung an verschiedenen Punkten berührt. ▪ Es gilt, auf eine Häufung von Sterbefällen mit den Leitsymptomen Atemnot und Angst im Bereich der Akutmedizin vorbereitet zu sein und die akutmedizinischen Strukturen in ihrer Kompetenz mittels klarer Handlungsempfehlungen und Beratung durch palliativmedizinische SpezialistInnen entsprechend zu stärken (Handlungsempfehlung 1). ▪ Zudem muss die palliativmedizinische Versorgung im ambulanten und stationären Sektor trotz erschwerter Rahmenbedingungen aufrechterhalten werden (Handlungsempfehlung 2). In der aktuellen Situation der COVID-19-Pandemie müssen viele Fragen der Therapiezielfindung, Indikationsstellung und Eruierung des Patientenwillens bei PatientInnen mit COVID-19-Erkrankung beantwortet werden. Empfehlungen zu "Entscheidungen über die Zuteilung von Ressourcen in der Notfall-und der Intensivmedizin im Kontext der COVID-19-Pandemie" wurden von der Arbeitsgemeinschaft Ethik in der Medizin in Zusammenarbeit mit medizinischen Fachgesellschaften (darunter der DGP) formuliert [1]. Die Herausforderung von Triage-Konzepten vor dem Hintergrund eingeschränkter intensivmedizinischer Behandlungskapazitäten auch mit der möglichen Konsequenz der Beendigung einer bereits begonnenen Intensivbehandlung aufgrund fehlender Erfolgsaussichten wird ausführlich in der Ad-hoc-Empfehlung "Solidarität und Verantwortung in der Corona-Krise" des Deutschen Ethikrats diskutiert [2]. Angesichts der zu erwartenden komplexen medizinethischen Dilemmata ist die Einbindung der palliativmedizinischen Expertise zur Festlegung von realistischen patientenzentrierten Therapiezielen sowohl bei der Entwicklung von Konzepten als auch bei konkreten Entscheidungen im Einzelfall sinnvoll und notwendig.
Background: Nausea and vomiting are common symptoms in patients with malignant disease. Several, sometimes rare causes have to be considered to decide the right treatment. Case Report: We report of a patient suffering from advanced breast cancer and complaining of severe nausea and vomiting over several weeks without any successful treatment. Later on, she developed marked hyperpigmentation of the skin and hypo-osmolar dehydration. Adrenal enlargement was noted in an abdominal scan. The suspected diagnosis of primary adrenocortical insufficiency due to metastases was confirmed by laboratory tests. After replacement therapy with hydrocortisone and fludrocortisone, the general condition of the patient improved dramatically and the symptoms of nausea and vomiting disappeared completely. Conclusion: If a patient with advanced cancer presents with unexplained and protracted nausea, vomiting and weakness, particularly if accompanied by hyponatremia and normal potassium levels, adrenal insufficiency due to adrenal metastases should be considered.
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