Spreadsheet: 139498d1328276114-excel-2007-copy-data-from-cells-in-one-workbook-to-another-based-on-the-cell-headings-jama-eletters-data
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305 9 923 | Response ID | Status | Title, Author | Responder | [NAME] | Response
 | jama_el;580 | P | Palliative Medicine demonstrates goals of care in an elderly patient [NAME], January 26, 2010 | [NAME],  MD  Metropolitan Hospital Center HHC NY NY | [EMAIL] | This is an elderly female with a myriad of medical problems all with a high symptom burden and a psychiatric comorbidity. As a Palliative Medicine physician I would first and foremost call a family meeting, to include Ms H, her daughter and other family members who the patient deemed necessary and I would ask her primary care doctor, her cardiologist, her psychiatrist and a hospice representative to be present at the meeting.   Initially I would ask the patient what is the most distressing issue that she has and what she sees would be an outcome that would make her satisfied.   I would want to find out if the patient had untreated pain, if she felt that cognitively she was declining and if her physical disability was overwhelming to her and then ask her one more very important question:   Did she had any hope for anything in the future? I would listen without judgement to her answer and hope that her family members could gain some insight, peace and closure from the patient's answer.   [NAME] prognosis is guarded at best and her clinical options are purely palliative as she has many medical conditions none of which are curable and all of which have progression of disease as an endpoint. The most important issues for patients and families facing the end of their life is to feel secure and hopeful that their decisions are understood fully and that the goals of care that the family unit has decided on are carried out by the caregivers on the team. [NAME] is a model of care for patients with a life-threatening illness with limited prognosis which focuses on quality of life and addresses multiple dimensions of suffering through an interdisciplinary team (1). [NAME] will help to control the cardiac dyspnea, painful diabetic neuropathy and her psychosocial / spiritual distress. In terms of timing, while hospice cannot intentionally hasten death, they can support the patient in discontinuing unwanted life prolonging interventions, including disabling the implanted cardiac device (2,3,4). Patients and families can make a decision about enrolling in hospice if their medical and psychosocial needs can be met by the hospice.   A referral can be made and the hospice intake staff member can explain the hospice philosophy and the scope of services. The outcomes of hospice care are patient and family satisfaction through better symptom management and avoiding unwanted hospital admissions and focusing on a comfortable end of life, with as little pain, discomfort and anxiety as possible (5). The psychosocial support for the family , including ongoing bereavement after death is also an important part of hospice services. Medical costs are usually contained to the hospice benefit for appropriate medicines prescribed for symptom management. As a Palliative Medicine physician I think hospice care is appropriate for this patient and family.   References   1 ) Hospice services satisfaction: mean section score for overall assessment questions on hospice services survey. Hospice services survey, South Bend In Press Ganey Associates, Inc 2004 4 p   2) Heart disease and [NAME]; Am I ready for Hospice care. [NAME] RN About .com Guide   3) Ballentine JM. Ethical Concerns Identified Regarding Deactivating Pacemakers and ICDs in competent hospice patients: an ethical consideration. Am J Hospice and Palliative Care 2005;22(1):7-8   4) Terminally ill Patients. Heart Rhythm Society 2006 Session AB26-6, May 18, 2006.   5) Steele LL. Patient and caregiver satisfaction with end of life care: does high satisfaction mean high quality of care? Am Journal of Hospice and Palliative Medicine 2002;19(1)
 | jama_el;567 | P | A UK Approach To Complex Palliative Care Management [NAME], January 23, 2010 | [NAME],  MD  Hull York Medical School, University of Hull | [EMAIL] | â€¢ What are Mrs. [NAME]'s prognosis and her clinical options/recommendations?   Her poor prognostic indicators include (1,2): NYHA IIIB; cachexia; medication intolerance; hospitalization; renal dysfunction; anaemia. She is not hypotensive, hyponatraemic, nor proteinuric. BNP is unknown.   Her prognosis is best assessed using biomarkers and clinical experience (e.g. "the surprise question ") (3) rather than a score.   â€¢ Clinical options: 1. Optimizimed heart failure treatment including co-morbidities, with an emphasis on symptom relief. 2. Withdraw ICD support to be consistent with "do not attempt CPR" order. 3. Multi-professional assessment including psycho-social-spiritual domains. â€¢ Dyspnoea: may benefit from non-pharmacological interventions and low dose opioids (4;5). â€¢ Nutritional review: there may be nausea, poor oral hygiene, constipation or fatigue affecting intake, rather than true cardiac cachexia. â€¢ Insomnia may be treatable and contributes to depression. â€¢ Review depression management? [NAME] discussion of concerns and what can be offered may change her understanding and fears.   â€¢ What are the issues are most important to patients and families facing the end of life?   Symptom control, avoiding a prolonged death, maintaining control, not being a burden and strengthening important relationships, preparation for death, life completion, and dignity feature strongly. Although many choose to die at home, this was only ranked 10th in importance in a patient survey. (6)   â€¢ What is hospice and what does it offer?   [NAME] provides palliative care: "â€[NAME] an approach that improves the quality of life [NAME] relief of suffering by means of [NAME] assessment and treatment of pain and other problems." [WHO]   UK Specialist Palliative Care (SPC) services are multi-professional and integrated into all health-care settings. Patients retain access to other specialties. A range of services (in/out-patient, day care or domiciliary) is provided.   â€¢ How may hospice help address the timing and mechanism of the end of her life?   Palliative clinicians can help with withholding/withdrawing decisions. Community advanced planning,(3) supported by hospice advice (7)can reduce inappropriate admissions.(8) Tools such as the Liverpool Care Pathway (9) prompts good care for the dying.   Current UK law obviates assisted suicide, and as this is a complex debate, we have not discussed this here. Once her difficulties and cry of distress are identified and addressed, [NAME] may no longer see suicide as her only option. If this wish remains, it should be acknowledged non-judgmentally.   â€¢ How do patients and families make decisions about enrolling in hospice?   A lay misconception persists that "hospice" is for the imminently dying. This is not the case. Many patients are discharged after a period of respite care or modification of treatment regimen. UK SPC care is free and not time- limited.   â€¢ What are the outcomes (e.g. patient, family, costs/utilisation) of hospice?   Patient: relieved symptoms (all domains), involvement in decisions, caregiver support (reducing burden-guilt) and preferred place of care.   Family: reduced caregiver burden/distress, improved bereavement: reduced isolation - somewhere to turn to.   Costs: reduced health resource use; futile interventions. Standard measures may not capture user relevant outcomes such as self efficacy and isolation.(10)   Corresponding author: Dr [NAME], Senior Lecturer in Palliative Medicine, Hull York Medical School, HYMS,[NAME], University of Hull, [NAME], East Yorkshire   Amanda Crundall, Lead Heart Failure Nurse Practitioner, Hull & East Yorkshire Hospitals NHS Trust, Honorary Research Associate, University of Hull   Professor [NAME], Professor of Cardiology, University of Hull, Honorary Consultant Cardiologist, Hull & East Yorkshire Hospitals NHS Trust   The authors have no relevant financial interests.   [NAME]   (1) [NAME], [NAME] PC, [NAME], [NAME], Naimark D, [NAME]. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 2003 Nov 19; 290(19): 2581-7.   (2) [NAME], Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, et [NAME]. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation 2006 Mar 21; 113(11): 1424-33.   (3) [NAME] The Gold Standards Framework: a programme for community palliative care. Department of Health 2009 [cited 2009 Jul 9]; Available from: URL: http://www.goldstandardsframework.nhs.uk/   (4) [NAME], Booth S, Gysels M, [NAME]-pharmacological interventions for breathlessness in advanced stages of malignant and non- malignant diseases. [NAME] Rev 2008;(2): CD005623.   (5) Currow DC, [NAME]. Pharmacological management of dyspnoea. Curr Opin Support Palliat Care 2007 Aug; 1(2): 96-101.   (6) Steinhauser KE, [NAME], Clipp EC, McNeilly M, [NAME], Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000 Nov 15; 284(19): 2476-82.   (7) [NAME], Harper A, Elliker M. Introducing 'Palcall': an innovative out-of-hours telephone service led by hospice nurses. Int J Palliat Nurs 2005 Nov; 11(11): 586-90.   (8) Johnson M, Parsons S, Raw J, Williams A, [NAME] preferred place of death - is it possible for patients with chronic heart failure? [NAME]. 2009;16(4):194-196.   (9) Ellershaw J, Murphy D, Bloger M, [NAME] The Liverpool Care Pathway For thTe Dying Patient (LCP). [NAME] Liverpool 2007 September 1 [cited 2009 Jul 9]; Available from: URL: http://www.endoflifecareforadults.nhs.uk/eolc/files/F2091- LCP_pathway_for_dying_patient_Sep2007.pdf   (10) [NAME] outcomes in palliative care: limitations of QALYs and the road to PALYs. J Pain Symptom Manage 2009 Jul; 3 8(1):27- 31.
 | jama_el;563 | P | Management of diabetes at end of life [NAME], January 18, 2010 | [NAME],  RN, CNP, PhD  Mayo Clinic | [EMAIL] | What are the appropriate decisions at the end of life when management of diabetes mellitus (DM) has required insulin? From the clinician's perspective, decisions about insulin administration at the end of life have been based on symptom control and the need to limit invasive procedures. (1) Others have questioned whether continuing insulin at the end of life is life prolonging or if discontinuing insulin hastens death. (1-3) Current practices and options for care vary widely and include reduced monitoring with administration of short acting insulin (possibly placing the patient at greater risk of hypoglycemic events), continuation of the patient's previous management regimen tailored to oral intake, and discontinuing glucose monitoring and insulin administration (2, 4-7).   Stopping insulin in a patient such as Mrs H with type 1 diabetes would likely hasten death from fatal ketoacidosis.(3) Inadequate insulin could lead to symptoms of hyperglycemia (dry mouth, confusion, restlessness) and if so [NAME] fear of painful death could be alleviated by administration of insulin. Treatment decisions based on symptoms, however, would be challenging in the unconscious patient where osmotic effects of hyperglycemia (thirst, dry mouth) may not be voiced as pain and discomfort, but observed as restlessness. At present, there is a lack of evidence as to whether dying patients become symptomatic from hyperglycemia.(2) There is also lack of evidence regarding optimal blood glucose levels at the end of life.(1)   We prefer a systematic approach such as that suggested by [NAME] and colleagues for the management of chronic conditions in patients with life-limiting illnesses.(8,9) This approach is based on the original therapeutic intent (primary, secondary, or tertiary prevention) of the treatment/medication. For example, drugs such as statins prescribed for primary prevention could be discontinued. In contrast, continuing drugs such as insulin prescribed for tertiary prevention should be considered into the terminal phase. Decisions to adjust drugs for symptom control based on the aims of the intervention need to be made as changes occur at end of life. One needs also to consider the potentially negative psychological impact of stopping long term treatments. Although Mrs H's current insulin administration and monitoring regimen are not described in the case, we would recommend less aggressive monitoring and establishing blood glucose stability with long-acting insulin.   References   1. Quinn K, Hudson P, [NAME] management in patients receiving palliative care. Journal of Pain and Symptom Management. 2006;32(3):275-286.   2. [NAME] R, [NAME], [NAME], [NAME] diabetes mellitus in patients with advanced cancer: a case note audit and guidelines. European Journal of Cancer Care. 2005;14(3):244-248.   3. [NAME] The management of diabetes in patients with advanced cancer. Journal of Pain and Symptom Management. 1997;13(6):339-346.   4. Ford-Dunn S, Smith A, Quin J. Management of diabetes during the last days of life: Attitudes of consultant diabetologists and consultant palliative care physicians in the UK. Palliative Medicine. 2006;20(3):197- 203.   5. Ford-Dunn S, Smith A, [NAME] of consultant diabetologists and consultant palliative care physicians on the management of diabetes during the last days of life. Diabetic Medicine. 2004;21(Suppl 2):83.   6. Smith A, Ford-Dunn S, Quin J. Management of diabetes during the last days of lifeâ€”a retrospective survey of dying patients in the hospital and hospice settings. Diabetic Medicine. 2004;21(Suppl 2):83.   7. Ford-Dunn S, Quin J. Management of diabetes in the terminal phase of life. Pract [NAME]. [NAME].   8. Stevenson J, [NAME], [NAME], Currow DC. Managing comorbidities in patients at the end of life. British Medical Journal. 2004;329(7471):909-912.   9. Currow DC, [NAME]. The broader implications of diabetes management at the end of life. Palliative Medicine. 2006;20(6):638-639.   Additional Mayo-Clinic affiliated authors: [NAME], RN, PhD; [NAME], RN, PhD; [NAME], RN, PhD; [NAME], MD   No relevant financial interests.
 | jama_el;553 | P | Hospice for Mrs. H: A breath of fresh air? [NAME], January 8, 2010 | [NAME],  MD  Proteion Thuis, [NAME], the Netherlands | [EMAIL] | The unpredictable disease trajectory of chronic heart failure makes it difficult to accurately predict prognosis of survival of Mrs. [NAME]) However, her renal impairment, edema and cachexia show that her chronic heart failure is shifting from the supportive and palliative care phase towards the terminal care phase.(2) Mrs. [NAME] should be offered a thorough interdisciplinary assessment of physical symptoms, care needs, psychosocial and spiritual needs.(3)   To date, no criteria exist to accurately predict appropriate timing for hospice care for patients with end stage chronic heart failure.(4) Therefore, decision for hospice referral can't be based on prediction of prognosis of survival alone, but should be guided by the patient's needs and preferences for end-of-life care. Hospice can provide Mrs. [NAME] a holistic assessment of physical, psychosocial, and spiritual needs and can offer a care management plan, according to these needs and her preferences. For [NAME], some palliative interventions seem possible which may reduce her daily suffering and improve quality of life. For example, a management plan which addresses factors contributing to her dyspnea with minimal exertion can consist of reassessing her (heart) medication (2) and symptomatic treatment of dyspnea with opioids.(5) Furthermore, an occupational therapist can teach energy conservation techniques and advice in optimal use of aids. In addition, the interdisciplinary care team can support her in improving her mobility and possibilities for interaction with her surroundings.   Mrs H already decided to forego resuscitation or mechanical ventilation. It is important to communicate her preferences for life- sustaining treatments with her loved ones and professional caregivers, to ensure that her wishes for end-of-life care will be respected. Further course of her disease needs to be discussed in detail and attention needs to be paid to dying and what dying might be like.[2, 6] Possibilities for terminal care should be discussed.   An optimal palliative care program is expected to reduce her suffering. However, there are limits to how much palliative care can make things right for Mrs. [NAME] It is reasonable to assume that not all her problems can addressed according to her wishes. For example, while hospice can provide care with (instrumental) activities of daily living and can offer counseling in coping with dependency, progress of her disease is likely to cause increasing dependency on others. In the Netherlands, it is possible to fulfill a patient's wish to end her life by euthanasia. By law, euthanasia can be performed only if there exists no reasonable alternative in the light of the patient's situation, the patient's suffering is unbearable, and no prospect of improvement exists.(7) This means that euthanasia is allowed only after treatment with every type of available curative or palliative care has been considered.(7) Although [NAME] is considering ending her life, at this moment it remains unclear if she has a voluntary and carefully considered wish to die. Furthermore, palliative care may prevent unbearable suffering. Hospice can help her to elicit her preferences for end-of-life care and provide optimal quality of life and optimal quality of dying.   1. [NAME], Kendall M, [NAME], [NAME] trajectories and palliative care. BMJ. Apr 30 2005;330(7498):1007-1011.   2. Jaarsma T, [NAME], Ryder M, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. May 2009;11(5):433-443.   3. World Health Organisation. WHO definition of palliative care. http://www.who.int/cancer/palliative/definition/en/ accessed 22/05/2007.   4. Coventry PA, Grande GE, [NAME], Todd CJ. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age Ageing. May 2005;34(3):218-227.   5. [NAME], Davies AN, [NAME], [NAME] for the palliation of breathlessness in terminal illness. [NAME] Rev. 2001(4):CD002066.   6. Curtis JR, Engelberg RA, Nielsen EL, Au DH, [NAME]. [NAME] physician communication about end-of-life care for patients with severe COPD. Eur [NAME] 2004;24(2):200-205.   7. [NAME], Alsemgeest TP, Widdershoven GA, Wouters EF, Schols JM, [NAME]. The last wish of a patient with end stage chronic obstructive pulmonary disease. BMJ. 2008;337:a2701.