Journal of palliative medicine
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Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA). ⋯ As a recognized leader in end-of-life care, the VHA can play a unique role in the development of specific interventions that address the diverse needs of persons with different dying trajectories identified through this research.
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The processes surrounding psychological adjustment to losses due to advancing and end-stage illness have not been well delineated. While adjustment to losses due to death are often thought of as the bereaved's lot, dying persons experience multiple, accumulating, and profound losses of functions, abilities, roles, and relationships and therefore have to adjust as well. Many people who are facing death in the near future negotiate these losses, still achieving quality of life in all dimensions. ⋯ We term this the reintegration model. It has comprehension, creative adaptation and reintegration components, each involving the physical, psychological, social, and existential domains in ways that are characteristic of the needs, tasks and options available to a seriously ill and dying person. In this paper, we discuss the model, focusing on normal adjustment processes, and describe the implications of the framework for the dying person, caregivers, and the palliative care team.
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Randomized Controlled Trial Clinical Trial
Can we predict which patients with refractory dyspnea will respond to opioids?
Dyspnea is frequently encountered in end-stage diseases even when reversible issues are addressed. Which clinical factors best define patient subpopulations that will most predictably benefit from opioids in this clinical setting? ⋯ Phase 4 pharmaco-vigilance trials are needed in palliative care to define people who are most likely to experience a net benefit from treatment such as opioids for refractory dyspnea.
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Although intravenous midazolam and flunitrazepam are frequently administered for primary insomnia in Japan, there is no empirical study on their efficacy and safety. ⋯ Intravenous midazolam and flunitrazepam appeared to be almost equal about efficacy and safety for primary insomnia, but flunitrazepam is less expensive and shows lower risk of tolerance development. A future prospective comparison study is necessary.
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Previous studies of end-of-life experience have been conducted primarily in urban medical centers and mostly focused on preferences for rather than experience of care. ⋯ Opportunities exist in community health care settings to improve quality of life for people approaching life's end. Clinicians, patients, and patients' families can contribute by engaging in open and ongoing communication about preferences for care, symptoms and their management, activities designed to enrich patients' personal experiences, as well as having patient care coordination and continuity of care on nights and weekends.