Outpatient clinics are increasingly being recognized for their critical role in facilitating early palliative care access. This systematic review highlighted the lack of consensus in the literature on which patients should be referred in the ambulatory setting. Cancer diagnosis, prognosis, physical symptoms, performance status, psychosocial distress, and end-of-life care planning needs may be taken into consideration when appropriate candidates are being identified.
Context Few studies have examined variation in vital signs in the last days of life. Objectives We determined the variation of vital signs in the final two weeks of life in patients with advanced cancer and examined their association with impending death in three days. Methods In this prospective, longitudinal, observational study, we enrolled consecutive patients admitted to two acute palliative care units and documented their vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature) twice a day serially from admission to death or discharge. Results Of 357 patients, 203 (55%) died in hospital. Systolic blood pressure (P < 0.001), diastolic blood pressure (P < 0.001), and oxygen saturation (P < 0.001) decreased significantly in the final three days of life, and temperature increased slightly (P < 0.04). Heart rate (P = 0.22) and respiratory rate (P = 0.24) remained similar in the last three days. Impending death in three days was significantly associated with increased heart rate (odds ratio [OR] = 2; P = 0.01), decreased systolic blood pressure (OR = 2.5; P = 0.004), decreased diastolic blood pressure (OR = 2.3; P = 0.002), and decreased oxygen saturation (OR = 3.7; P = 0.003) from baseline readings on admission. These changes had high specificity (≥80%), low sensitivity (≤35%), and modest positive likelihood ratios (≤5) for impending death within three days. A large proportion of patients had normal vital signs in the last days of life. Conclusion Blood pressure and oxygen saturation decreased in the last days of life. Clinicians and families cannot rely on vital sign changes alone to rule in or rule out impending death. Our findings do not support routine vital signs monitoring of patients who are imminently dying.
Context Although off-label medications are frequently prescribed in palliative care, there are no published studies examining their use in the United States. Objectives We examined the frequency of off-label medication use in cancer patients admitted to an acute palliative care unit (APCU). Methods This prospective observational study enrolled consecutive patients with advanced cancer admitted to the APCU of a tertiary care cancer center. We collected data on all prescription events, including indications for use, from admission to discharge. Off-label use was checked against the U.S. Food and Drug Administration approved indications. Results Among the 201 patients, median survival was 10 days (95% confidence interval 7-13), and 85 (42%) patients died in the APCU. We documented 6276 prescription events, and 2199 (35%) were off-label. Among off-label prescriptions, central nervous system agents (n=1606, 73%), hormones and synthetic substitutes (n= 302, 14%), and autonomic drugs (n=183, 8%) were most commonly prescribed. Haloperidol (n=720, 33%), chlorpromazine (n=292, 13%), dexamethasone (n=280, 13%), glycopyrrolate (n=175, 8%), hydromorphone (n=161, 7%), and morphine (n=156, 7%) were most frequently prescribed off-label. The most common indications for off-label prescribing were delirium (n=783, 36%) and dyspnea (n=449, 20%). 70% of all off-label prescription events had strong evidence supporting use, and 19% of prescription events had moderate or weak evidence for use. Conclusion One-third of prescription events in the APCU were off-label, with majority of off-label use having a strong level of supporting evidence. Our findings highlight the need for more research in key areas such as delirium and dyspnea management.
This study analyzed palliative/supportive care use in a single cancer center over 8 years. Billing data showed the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds almost doubled. In the outpatient setting, data revealed earlier access to outpatient referrals to palliative care service (from 4.8 months to 7.9 months; p = .001) during the study period.
Context Few studies have examined the frequency of unexpected death and its associated factors in a palliative care setting. Objectives To determine the frequency of unexpected death in two acute palliative care units (APCUs); to compare the frequency of signs of impending death between expected and unexpected deaths; and to determine the predictors associated with unexpected death. Methods In this prospective, longitudinal, observational study, consecutive patients admitted to two APCUs were enrolled and physical signs of impending death were documented twice daily until discharge or death. Physicians were asked to complete a survey within 24 hours of APCU death. The death was considered unexpected if the physician answered “yes” to the question “Were you surprised by the timing of the death?” Results In total, 193 of 203 after-death assessments (95%) were collected for analysis. Nineteen of 193 patients died unexpectedly (10%). Signs of impending death, including nonreactive pupils, inability to close eyelids, decreased response to verbal stimuli, drooping of nasolabial folds, peripheral cyanosis, pulselessness of the radial artery, and respiration with mandibular movement, were documented more frequently in expected deaths than unexpected deaths (P < 0.05). Longer disease duration was associated with unexpected death (33 months vs. 12 months, P=0.009). Conclusion Unexpected death occurred in an unexpectedly high proportion of patients in the APCU setting, and was associated with fewer signs of impending death. Our findings highlight the need for palliative care teams to be prepared for the unexpected.
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