Journal of palliative medicine
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Review
Dyspnea review for the palliative care professional: treatment goals and therapeutic options.
Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. ⋯ In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.
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Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness. ⋯ The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.
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Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. ⋯ Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.
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Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. ⋯ Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.
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Recent end-of-life (EOL) care literature in non-Native American (NA) populations has demonstrated the benefits of EOL discussions. EOL discussions are associated with less aggressive care at EOL, better patient self-assessed quality of life, and less caregiver depression after the patient is deceased. There is no literature assessing these issues in NA populations. However, common myths that may affect care include: 1) NA patients will not discuss death and dying, 2) severely ill NA patients and families will not choose do not resuscitate (DNR) status, and 3) NA patients and families will not utilize hospice services if offered. ⋯ Study results demonstrate that health care providers can hold EOL care discussions with NA patients and NA patients' care preferences are affected by these discussions. The result do not support our hypothesis that there would be a lower rate of post-consult DNR status in NA patients (compared with non-NA). NA and non-NA patients and families participated in family meetings and their code status was affected to a similar degree. Furthermore, NA patients and their families choose hospice services at rates similar to non-NA patients seen by the palliative care consultation service.