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Hospital ethics committees (HECs) are typically charged with addressing ethical disputes, conflicts, and dilemmas that arise in the course of patient care. HECs are not widely viewed as having a therapeutic role for health care professionals who experience psychological distress or anticipatory grief in the course of discharging professional duties. A case is presented in which an ethics consultation was requested, chiefly, to secure emotional support for health care professionals who had been asked by a patient to discontinue life-sustaining treatments. As the case demonstrates, HECs may be called upon to provide emotional support and reassurance to health care professionals who willingly carry out psychologically difficult actions, even though these actions may be ethically uncontroversial. In providing this service, the HEC may not necessarily engage in its customary activity of deliberating an ethics issue and resolving a conflict but may still provide valuable assistance, as in the case presented. [ABSTRACT FROM AUTHOR]

The article discusses the pathophysiology associated by dyspnea and explains the impacts caused by opioids on this observed pathophysiology. Oxygen, carbon dioxide and pH and central nervous system (CNS) functions play significant roles in dyspnea, which is generally associated with shortness of breath and other breathing problems. The use of opioids is shown to be beneficial in dyspnea patients, as they enhance respiration and can render survival advantages in situations.

Objective: To evaluate the efficacy and safety of oral transmucosal fentanyl citrate (OTFC) in terminally ill patients experiencing dyspnea. Methods: Nonblinded, noncontrolled observational study of patients admitted to the hospice/palliative care unit for dyspnea from May 2006 to March 2007. Eligible patients were older than 18 years of age with satisfactory baseline cognitive function diagnosed with end-stage congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer complaining of dyspnea. At the onset of dyspnea, enrolled patients were instructed to slowly dissolve the OTFC lozenge and rate their dyspnea on a 10 point visual analog scale at 15-minute intervals for 60 minutes. Respiratory rate (RR) and arterial oxygen saturation (SaO2) were recorded at similar intervals. Patients were observed for approximately 48 hours. Results: Four patients were found eligible. In all four cases, patients experienced rapid relief of dyspnea as soon as five minutes. No significant adverse events were reported. Conclusions: OTFC appears to be safe and effective for dyspnea in terminally ill patients. The study population is limited to four cases, however, the initial findings are promising and merit further research. [ABSTRACT FROM AUTHOR]

Objectives: To report on quality of care in a Veterans Affairs (VA) dedicated hospice unit. Design: Mortality follow-back survey of bereaved family members, using a quality of care instrument. Setting: A VA inpatient hospice unit. Participants: Bereaved family members. Measurements: Satisfaction with care as perceived by family members using a telephone survey. Results: 159 family members were contacted with 102 completing full and 37 completing abbreviated surveys. (Overall response rate: 87.4%, complete responses: 64.2%) 98% of all respondents reported overall quality of care as Excellent or Very Good. Conclusion: High levels of satisfaction were reported by family members. Implications of this initiative for the provision of hospice care in nursing homes are discussed, including replication of the model in both VA and non-VA nursing home settings. [ABSTRACT FROM AUTHOR]

Presents a case study of an older woman who was diagnosed with Capgras syndrome following morphine treatment. Medical history of the patient; Clinical manifestations of Capgras syndrome; Mechanism and prognosis of Capgras syndrome.

Reviews several experiences of cancer patients receiving reverse rotation of methadone and examines the role of the methyl aspartate (NMDA) receptor. Effectiveness of NMDA receptor antagonists in treating neuropathic pain; Information on opioid tolerance; Role of the NMDA receptor in opioid-induced pain, opioid tolerance and chronic pain states.

Providing care to actively dying patients presents unique challenges for the clinician. Patients in their final days require careful symptom management. Families need support and coaching as death approaches. Care does not end with the death of the patient but continues through death pronouncement, family notification of the death, discussion of autopsy, and immediate bereavement support. Skills in these and related areas are discussed in the context of one man’s death, as illuminated by comments made after death by his daughter and his physician. This case also highlights the often differing perspectives of families and clinicians as they work to deal with a patient’s death. A goal of mastering the palliative skills necessary to competently care for an actively dying patient is to enable a patient to die peacefully and relatively free of discomfort. Achieving such competency should also help to relieve clinician stress attendant to caring for dying patients. [ABSTRACT FROM AUTHOR]

Presents a case study of an aged Vietnamese man diagnosed with deep vein thromboembolism. Medical background of the patient; Clinical manifestations of deep vein thromboembolism; Influence of culture on clinical management.

Large bowel obstruction in the terminally ill patient can be difficult to manage. We describe a patient with sigmoid colon obstruction caused by metastatic prostate cancer in the pelvis who required hospitalization because of severe pain and obstructive symptoms. Treatment with an endoscopically placed self-expandable metal stent allowed the patient to have immediate resolution of symptoms and to receive hospice care at home. [ABSTRACT FROM AUTHOR]

Focuses on the ethical implications of applying terminal sedation (TS) in different situations. Examples of situations where TS could be applied; Principles that guide the ethical use of TS; Arguments regarding the application of TS and physician intent.

Deals with issues arising from different cultural perspectives in the United States that affect decision making at end-of-life care. Illustration of a common medical situation that highlights Western ethical principles; Examples of cultural differences; Views on cultural competence.

Provides information on a study that evaluated intern experience in the end-of-life care and self-assessed changes in attitude and knowledge on an inpatient hospice and in a nursing home. Methodologies used; Results and discussion.

The article presents the author's views on the shortcomings in the health care system with regards to palliative care in the cultural and societal perspectives. The author imparts that education can bridge the gap which the culturally conservative approach of dealing with death and dying has created in the society and the medical culture. He hopes that palliative care should be accepted both as medical care specialty and as an integral aspect. It also mentions lessons learned by the author.

The author discusses on the palliative treatment and evidence-based medicine. He describes the difficulties of applying the latter paradigm to the former and reflects on the challenges faced by its researchers that are working to discover new knowledge in the social movement's context. Finally, he concludes that evidence-based methodologies are just one set of tools, but not necessarily best for understanding others.

The article comments on the paper by Amy M. Sullivan et al., which was published within the issue demonstrating a training program in palliative care which resulted in significant improvements in self-assessed competencies and behaviors relative to teaching and clinical care. It raises broader questions regarding the relationship between general internal medicine and palliative care.

Presents guidelines on the use of tube feeding in chronically ill and dying patients. Indications for tube feeding; Information on the prevention of aspiration pneumonia; Chronic illnesses in which tube feeding may be life-prolonging.

A response by James Hallenbeck to a letter to the editor about his article “Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death?” in the July 31, 2012 issue is presented.

The article offers the authors' insights on the series of case discussions in the "Journal of Palliative Medicine." They say that the discussions are most closely associated with how clinicians gain their knowledge to practice. They state that the goal of the series in the journal's volume three was to reproduce the type of discussion that occurs during a particular conference in a journal format. They add that a case discussion must be practical and present news that can be used by clinicians.

Discusses the role of case discussions in palliative medicine. Effects of a case discussion on medical issues; Opportunities for case authors; Benefits of case studies for palliative medicine fellows and junior faculty.

Focuses on the explanatory model of illness. Importance of inquiring about a patient; Use of the model in interpreting the culture of Western medicine; Tips on resolving conflicts in end-of-life care.

This article presents a case study regarding the treatment of pruritus caused by cholestasis with opioid antagonists. The patient in the case study had mild cholestasis caused by hepatic metastases. Pruritus and pain was caused by liver involvement by tumor. With increasing clinical experience, it may be possible to substantially shorten the duration of naloxone infusion, in order to initiate oral naltrexone therapy in cholestatic patients. To determine how applicable the approach outlined in a hospital daycare setting may be in a patient who is receiving palliative care and is also dependent on opiate agonist therapy for the relief of pain, further clinical experience is necessary.

Presents a case which describes a patient who had a history of alcoholism and developed severe respiratory depression after treatment for a complaint of pain. Results of the examination of the patient; Discussion on respiratory depression; Common medications with potential drug interaction with methadone.

Presents a case study which focused on the discontinuation of cardiovascular medications at the end of the life of an 83-year-old woman with congestive heart failure. Relationship of aging with the increase of the prevalence of hyperlipidemia; Benefits of lipid-lowering therapy; Burdens associated with lipid-lowering therapy.

Providing care to actively dying patients presents unique challenges for the clinician. Patients in their final days require careful symptom management. Families need support and coaching as death approaches. Care does not end with the death of the patient but continues through death pronouncement, family notification of the death, discussion of autopsy, and immediate bereavement support. Skills in these and related areas are discussed in the context of one man's death, as illuminated by comments made after death by his daughter and his physician. This case also highlights the often differing perspectives of families and clinicians as they work to deal with a patient's death. A goal of mastering the palliative skills necessary to competently care for an actively dying patient is to enable a patient to die peacefully and relatively free of discomfort. Achieving such competency should also help to relieve clinician stress attendant to caring for dying patients. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor in response to Davis' and Currow's comments on the article "Discontinuing Medications at the End-of-Life: Lipid-Lowering Agents," published in the 2005 issue of the "Journal of Palliative Medicine."

Background: In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery. Objective: To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project. Measurement: Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports. Results: Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. Conclusions: Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change. [ABSTRACT FROM AUTHOR]

Patients often experience `preparatory-grief' as they cope with the dying process. Some may be depressed. The Terminally Ill Grief or Depression Scale (TIGDS), comprising grief and depression sub-scales, is a new self-report measure designed to differentiate between preparatory-grief and depression in adult inpatients. The initial 100-item inventory was assembled based on literature review, interviews with clinicians and dying patients and then shortened to 42 items based on consensus expert opinion. Validity and reliability were tested in a sample of 55 terminally ill adults. The consensus clinical opinion was used as the gold standard to differentiate between preparatory grief and depression. The intra-class correlation coefficient was high (it was calculated to estimate the test-retest reliability for the 47 patients who had completed the TIGDS twice - retest was administered 2 to 7 days after the initial test), ranging from 0.86 (grief) to 0.97 (depression). The validity of TIGDS was assessed using a receiver operating characteristic curve analysis, comparing the first test with the clinical criterion. The first and only variable and cut-point was the depression score (chi-square = 18.4, p < 0.001, cut point = 3). The sensitivity of the TIGDS was 0.727 and specificity was 0.886 for the depression = 3 cutoff score. The construct validity of the TIGDS was tested by comparing with the Hospital Anxiety and Depression Scale (HADS). The TIGDS depression subscale showed strong convergent validity and the TIGDS grief subscale showed strong discriminant validity with the HADS total score. [ABSTRACT FROM AUTHOR]