Suncoast Hospice Institute

Acne vulgaris affects nearly 50 million people in the USA, ranking as the eighth most prevalent disease globally. This chronic inflammatory skin condition often results in sequelae, including atrophic acne scars, acne-induced macular erythema and acne-induced hyperpigmentation, impacting patients’ quality of life. This commentary article reviews the use of topical retinoids, with a particular emphasis on trifarotene cream 0.005%, for managing both acne and acne sequelae. Topical retinoids are considered central to improving treatment outcomes because of their established efficacy, safety and tolerability. Adapalene, tretinoin and tazarotene have demonstrated efficacy in reducing acne and acne sequelae in several studies. Trifarotene has been extensively studied in Phase 3 trials, demonstrating notable success in treating mild-to-moderate acne. Recently, two large-scale, randomized, blinded, Phase 4 clinical trials investigated trifarotene cream 0.005% in patients with atrophic acne scarring and acne-induced hyperpigmentation across all Fitzpatrick phototypes. The START study found that there was a greater reduction in total atrophic acne scar count in the trifarotene group compared with the vehicle group at Week 24 (55.2% vs 29.9%) with statistical significance established as early as Week 2 (P = 0.001). Based on this evidence, we recommend that topical retinoids should be introduced as first-line therapy for the treatment of acne and acne sequelae. Retinoids should be implemented into a treatment routine as early as possible, especially for patients with darker Fitzpatrick phototypes or patients at risk of atrophic acne scarring. Furthermore, retinoids should be incorporated within a comprehensive skincare regimen that includes adequate photoprotection when treating patients with darker Fitzpatrick phototypes. Finally, management of acne and acne sequelae should include maintenance therapy with topical retinoids. This article supports the American Academy of Dermatology’s call for acne sequelae treatment guidance and emphasizes the need for continued research to optimize patient care.

Death rattle, defined as noisy breathing caused by the presence of mucus in the respiratory tract, is relatively common among dying patients. Although clinical guidelines recommend anticholinergic drugs to reduce the death rattle after nonpharmacological measures fail, evidence regarding their efficacy is lacking. Given that anticholinergics only decrease mucus production, it is unknown whether prophylactic application may be more appropriate. To determine whether administration of prophylactic scopolamine butylbromide reduces the death rattle. A multicenter, randomized, double-blind, placebo-controlled trial was performed in 6 hospices in the Netherlands. Patients with a life expectancy of 3 or more days who were admitted to the participating hospices were asked to give advance informed consent from April 10, 2017, through December 31, 2019. When the dying phase was recognized, patients fulfilling the eligibility criteria were randomized. Of the 229 patients who provided advance informed consent, 162 were ultimately randomized. The date of final follow-up was January 31, 2020. Administration of subcutaneous scopolamine butylbromide, 20 mg four times a day (n = 79), or placebo (n = 78). The primary outcome was the occurrence of a grade 2 or higher death rattle as defined by Back (range, 0-3; 0, no rattle; 3, rattle audible standing in the door opening) measured at 2 consecutive time points with a 4-hour interval. Secondary outcomes included the time between recognizing the dying phase and the onset of a death rattle and anticholinergic adverse events. Among 162 patients who were randomized, 157 patients (97%; median age, 76 years [IQR, 66-84 years]; 56% women) were included in the primary analyses. A death rattle occurred in 10 patients (13%) in the scopolamine group compared with 21 patients (27%) in the placebo group (difference, 14%; 95% CI, 2%-27%, P = .02). Regarding secondary outcomes, an analysis of the time to death rattle yielded a subdistribution hazard ratio (HR) of 0.44 (95% CI, 0.20-0.92; P = .03; cumulative incidence at 48 hours: 8% in the scopolamine group vs 17% in the placebo group). In the scopolamine vs placebo groups, restlessness occurred in 22 of 79 patients (28%) vs 18 of 78 (23%), dry mouth in 8 of 79 (10%) vs 12 of 78 (15%), and urinary retention in 6 of 26 (23%) vs 3 of 18 (17%), respectively. Among patients near the end of life, prophylactic subcutaneous scopolamine butylbromide, compared with placebo, significantly reduced the occurrence of the death rattle. trialregister.nl Identifier: NTR6264.

This article offers a critical reflection on an allegory, “The Horse on the Dining-Room Table,” by Richard A. Kalish. After a brief review of Kalish's prolific publications during the mid-1960s to the late 1980s, the article turns to a detailed analysis of the three parts of the allegory. Next, there is a comparison of “The Horse on the Dining-Room Table” to a poem, “There’s an Elephant in the Room,” by Terry Kettering, with a table listing some similarities between the two texts. The article concludes with four lessons to learn from "The Horse on the Dining-Room Table.”

BackgroundGrowth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home.ObjectiveTo determine whether this increase in inpatient utilisation is consistent with patient preferences.DesignRetrospective cohort study.SettingSeven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network.Patients70 488 patients admitted between 1 July 2008 and 31 May 2012.MeasurementsWe measured changes in patients’ stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients’ actual site of death and concordance with patients’ preferences.ResultsMore patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001).LimitationsThis study included only seven hospices, and results may not be representative of the larger hospice population.ConclusionsAlthough more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.

This article focuses on Robert Kastenbaum's seminal concept of the societal death system. Beginning with conflicting claims that America is a death-denying society versus a death-accepting society, the article reports Kastenbaum's definition and description of the death system in American society and sets forth the seven functions and five elements or components of that death system. Next, the article notes Kastenbaum's further claim that "All cultures, past and present, have had death systems." Finally, two basic lessons are drawn from the foregoing: (1) Kastenbaum's concept of the death system provides a robust framework to explain the networks societies interpose between their members and death, focusing in particular on a more or less integrated and dynamic network within American society whose functions and components are not difficult to recognize in the ways in which they organize many aspects of the lives of individuals who live within that society; and (2) It is preposterous to assert without qualification that America is a death-denying society when there are so many activities and components within that society that are in whole or in part related to death, i.e., although it may be true that many aspects of the contemporary American death system appear to seek to remove death from the mainstream of life, there is ample evidence to indicate that American society as a whole and individuals within that society both accept and deny death simultaneously.

Harleah G. Buck, a board-certified hospice and palliative care nurse, is currently an assistant professor at the School of Nursing, Pennsylvania State University, University Park, Pa. She was formerly a nurse at The Hospice of the Florida Suncoast in Largo, Fla. Beth Fahlberg is a clinical associate professor at the University of Wisconsin-Madison School of Nursing. Issues in palliative and end-of-life care The authors have disclosed that they have no financial relationships related to this article.

Harleah G. Buck, a board-certified hospice and palliative care nurse, is currently an assistant professor at the School of Nursing, Pennsylvania State University, University Park, Pa. She was formerly a nurse at The Hospice of the Florida Suncoast in Largo, Fla. Issues in palliative and end-of-life care The author has disclosed that she has no financial relationships related to this article.

Harleah G. Buck, a board-certified hospice and palliative care nurse, is currently an assistant professor at the School of Nursing, Pennsylvania State University, University Park, Pa. She was formerly a nurse at The Hospice of the Florida Suncoast in Largo, Fla. Issues in palliative and end-of-life care The author has disclosed that she has no financial relationships related to this article.