United Hospice

AimsRecognition of when a person is approaching the last hours/days of life can be challenging for healthcare professionals with a search of the literature demonstrating that the dying phase is poorly recognised across different clinical and home settings. The provision of end-of-life-care for people approaching the last hours/days of life in Wales is supported by the All Wales Guidance: Care Decisions for the Last Days of Life (CDLDoL), however there is poor utilisation of this guidance in nursing homes (NH). A quality improvement project (QIP) was designed to evaluate if education on recognising the dying person and the CDLDoL would improve the utilisation of the guidance with the aim of improving the provision of end-of-life-care in NHs in the Cardiff area.MethodsThree NHs were recruited and ten teaching sessions across the three NHs were conducted. Data on all deaths was compared for a 6-month period pre- and post-intervention.ResultsBefore the teaching intervention, there were no residents (0%) that had their care guided by the CDLDoL. Following the teaching intervention, both qualified and non-qualified staff stated improved confidence in recognising when a person is approaching the end of life and providing end-of-life-care. 2 residents (6.5%) had their care guided by the CDLDoL and the percentage of residents with end-of-life medications prescribed at time of death increased from 56.5% – 76.2%.ConclusionThe QIP demonstrated that the teaching had a positive impact on the confidence levels of NH staff with improved provision of end-of-life-care. Further clinical research within the wider palliative care community on the dying phase should be conducted as well as further research into the perceived barriers and challenges of using the CDLDoL. The QIP will be extended across other NHs across Cardiff, as well as extending the teaching to GPs and community nurses.

\nTo the editor:\nMorbidity related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection continues to rise and includes acute and chronic pain.1 Multiple etiologies include viral-induced myalgia, neuropathic pain, tissue hypoxia-ischemia,2 and rhabdomyolysis. Iatrogenic causes include anticoagulation resulting in bleeding in patients who receive anticoagulation empirically based on elevated inflammatory markers.3\nWe recently treated a 68-year-old woman with nasopharyngeal-swab positive coronavirus disease 2019 (COVID-19) with acute-to-chronic pain after a left retroperitoneal bleed. She was hospitalized with fever, cough, myalgia, D-dimer of 3600?ng/mL and hemoglobin 12.6 gm/dL. She remained stable and was discharged with enoxaparin 90?mg injections twice daily while continuing on aspirin 81?mg daily.\nFour days later the patient developed back and leg pain with weakness and syncope. The patient's primary care physician was notified who suspected a common nerve injury. When symptoms worsened overnight the patient went to the emergency room where a low-back X-ray and lower extremity Doppler were negative. An MRI obtained 10 days after starting enoxaparin revealed a 900-cc left-sided retroperitoneal hematoma that was surgically drained but with no improvement in her lower extremity pain and weakness. After two months of in-patient rehabilitation the pain continued with 3?4/10 pain intensity at rest and 10/10 with movement. An electromyography (EMG) study four months after surgery revealed severe acute denervation of the femoral nerve, left lumbosacral plexopathy, distal left lower extremity entrapment neuropathy, and right femoral neuropathy.\nThe patient's pain was treated with Kadian 15?mg by mouth twice daily, to which was added morphine 2?mg IV every two hours as needed (PRN), alternating with oxycodone 5?mg q six hours PRN; gabapentin 100?mg three time daily (TID) orally; cyclobenzaprine 5?mg q eight hours PRN with a pain of 7/10 with activity. Increases of gabapentin to 300?mg twice daily (BID) and Biofreeze topical spray only reduced her pain to 3?5/10 at rest and 6/10 with activity. Because adequate pain control with acceptable side effects was difficult to achieve, tissue concentrations in the area of pain were targeted with a topical compounded cream of ketamine 15%, clonidine 2%, and gabapentin 4%/1?mL Lipoderm cream; applying 1.0?mL TID in the left femoral nerve cutaneous distribution. Ketamine was chosen for N-methyl-d-aspartate receptor (NMDAR) antagonism, clonidine for hyperpolarization of the afferent neuron membrane, and gabapentin continued topically for neuronal N-type calcium channel inhibition. Topical lidocaine was not included; our experience relegates topical lidocaine to use in mild-to-moderate pain.4 This augmented regimen reduced the pain to 0?2/10 during the day, despite activity, although after a day of extended activity the patient found oxycodone 5?mg PRN helpful for sleep.\nTreatment of pain during intercurrent COVID-19 including neuropathic pain from a retroperitoneal hematoma, as in this patient, may be facilitated by multimodal therapy including low doses of topical agents.\n

At the end of life, hospice patients frequently rely on surrogate decision makers (SDMs) for healthcare decisions, which creates anxiety among SDMs. This project evaluated whether an educational intervention to create a plan of care for hospice patients would reduce anxiety among SDMs. Before the intervention, immediately after the intervention, and 2 weeks following the intervention SDM anxiety was measured with the Geriatric Anxiety Scale, State Trait Anxiety Inventory-State Anxiety Scale, and one question about decision-making anxiety. Twelve patients (80±14.7 years) and 18 SDMs (60±12.9 years) completed the intervention. Immediately after the intervention SDMs showed a significant decrease (P=0.003) in anxiety. When anxiety was measured 2 weeks post-intervention, anxiety had increased again, and was no longer significantly different from pre-intervention levels. This project demonstrated that an educational intervention in the hospice setting can be effective in creating a short-term decrease to SDM anxiety levels.

The value of therapeutic storytelling within the context of psychological counseling--in which a counseling practitioner offers the client a story intended to facilitate processing, insight, and/or psychological growth--has been documented. Using a case study, the benefits of this kind of storytelling with a client who had a transpersonal experience is explored, particularly relating to providing education and normalizing and de-stigmatizing these experiences. A case is made for the value of literature, the lives of great writers, and the humanities generally as a source of potentially useful stories for mental health professionals interested in adding storytelling as an adjunct to counseling practice.

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

At the core of hospice remains the defining nature of mortals tending to other mortals facing diagnosed terminality. Such situations are pregnant with meanings. As mortals are subjective beings, social engagements become inundated with meaning differences. This alludes to the inescapable occurrence of collisions and conflicts in meaning. It would behoove us to make explicit the contention that exists in hospice care, given that death is the nonnegotiable outcome to be diversely faced by all involved persons whose lived approaches related to death issues may characteristically lack unanimity. Toward elucidating the inherently contentious nature of hospice care, the dynamical influence of external forces that overlie thanatological matters in society and the complex human dynamic in hospice care situations are discussed. Practice suggestions for hospice staff are offered.