Sleep problems appear to be a significant issue for advanced cancer patients. Attention to sleep disturbance needs to be incorporated into the routine practice in palliative care evaluation.
Hydration during palliative care is a controversial topic. Most of the arguments are based on anedoctal reports that have not been substantiated with scientific data. Given that the choice is problematic from a clinical perspective, preferences of patients and family should dictate whether intravenous fluids are administered. The aim of this study was to evaluate patient and family perceptions about hydration and two modes of providing hydration. Fifty-four consecutive patients admitted to an acute pain relief and palliative care unit who required hydration completed a questionnaire regarding their perceptions on hydration and modes of hydration. Similarly, the principal family carer was chosen and similar questions were posed. For most items, patients and relatives agreed, considering hydration as a useful medical treatment that is able to provide some nutrition. The intravenous route was considered able to improve the clinical condition and to have a positive psychological meaning, representing an acceptable burden. The subcutaneous route was considered less effective, and not less bothersome than the intravenous route. Most patients and relatives agreed with continuing hydration at home, if necessary, preferring the intravenous route. Other than technical considerations, which can be variable according to the clinical setting, the perceived benefits of artificial hydration by the caregivers and patients are central to the ethical, emotional, and cultural considerations involved in their decision making. Most patients and relatives surveyed accepted and were in favor of intravenous hydration.
The aim of this survey was to prospectively collect data about gastroprotector prescription at admission of an acute pain relief and palliative care unit. An observational survey was performed on three-hundred consecutive patients. Reasons for admission, concomitant treatment and use of drugs were recorded at admission. About 60.6% patients had been prescribed proton pump inhibitors or anti-H2 receptors agents. Of these patients, possible risk factors were nonsteroidal anti-inflammatory drugs (41, 22.5%), corticosteroids (43, 23.6%), age > 75 years (27, 14.8%). In only 25 admissions (13.7%) prescription corresponded to Italian drug agency recommendations with an odds ratio of an off-label prescription of 7.28. In a relatively high percentage of admissions (55%), patients receiving gastroprotectors were on chemotherapy, with an odds ratio of 1.42. This survey showed that gastroprotectors are often prescribed regardless of Health Care System regulations, as only a minority of patients satisfied the requirements of an appropriate and refundable prescription. The attitudes of oncologists who prescribe gastroprotectors for a putative protective effects are not supported by evidence. Health Care Service in Italy should be aware of these problems to improve the strategies of budgeting the drug expense in a better way or providing further guidelines based on studies able to demonstrate the real cost-benefit ratio of this class of drugs.
The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37-79), and 9 were males. The mean hospital stay was 7.7 days (range 3-14), and the mean Karnofsky level was 35 (range 10-50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinued the treatment during admission. Four patients (29%) started PN during hospital admission as decided by the staff. Twelve patients (85%) were discharged on PN. One week after hospital discharge, 9 patients were still receiving PN, 4 patients died, and no data were available for 1 patient. One month after hospital discharge only 2 patients of these were still on PN, 2 patients discontinued PN, and 5 patients died. This study shows that decisions to start or to stop PN were individually based on multiple considerations, not only clinical. Goals may vary from expected clinical benefits to compassionate use. The administration of PN should be assessed carefully and individually approached.
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