Journal of palliative medicine
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The successful practice of hospice and palliative medicine requires basic knowledge of its medicolegal aspects. In this paper, we review several recent legal cases that highlight important, evolving legal issues in palliative medicine. These issues include efforts to change to advance directive laws after the Schiavo conflict, the Attorney General's challenge to Oregon's physician-assisted dying law, and the emergence of a tort for inadequate pain management. Despite conflicting attitudes about key issues in end-of-life care, the courts' decisions in these cases have consistently advanced the interests of hospice and palliative care practitioners.
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Delirium, a common complication of advanced cancer, may put caregivers at risk for poor mental health outcomes. We looked for a relationship between caregiver-perceived delirium in a patient with advanced cancer and rates of caregiver psychiatric disorders. ⋯ This is the first report of an association between caregiver-perceived delirium and a caregiver mental health outcome. Further studies, using improved measures of delirium, are needed.
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Cancer-related fatigue (CRF) is the most common symptom experienced by patients with cancer. Clinically important improvement in the intensity of fatigue in palliative care patients has not been well established. We reviewed the data from 3 clinical trials of fatigue in 194 patients receiving palliative care treatment. ⋯ Results showed the mean patient age was 56 (+/-12) years, and 37% were men. A reduction of approximately 10 points in FACIT-F (sensitivity = 73%, specificity = 78%, area under the curve = 0.82) and 4 points in ESAS fatigue (sensitivity = 66%, specificity = 72%, area under the curve = 0.78) score was best able to predict a clinically important improvement (GBS >/= 4). We were able to characterize the relationship between FACIT-F and ESAS scores and patients' global perception of improvement but further studies are needed to validate our findings.
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Palliative care services can decrease physical and psychosocial distress in patients with advanced cancer. However, most patients with cancer die without access to palliative care services (APCS), and patterns of referral are not well understood. The purpose of this study was to determine predictors of patients' access to palliative care. ⋯ APCS was lower among patients with hematologic malignancies and those admitted to the ICU. APCS resulted in a lower cost of care. Mortality in comprehensive cancer centers is quite variable among different primary malignancies. More research is needed to better define patterns of referral.
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There are wide variations in hospital-level treatment intensity at the end of life that are not entirely explained by structural and market characteristics. Individual hospital microclimates must exist to perpetuate these practice variations. ⋯ Discrimination of differences in microclimates related to norms of treatment intensity at the end of life is feasible, but greater specificity of measurement will be required to explain objective measures of terminal admission treatment intensity.