2020; Volume 21, No 3, March
Lessons from the Literature
Under My Microscope
Dr. Tania Pastrana. Used with permission.
IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
Dexmedetomidine: A Novel Strategy for Patients with Intractable Pain, Opioid-Induced Hyperalgesia, or Delirium at the End of Life.
Hofherr ML, Abrahm JL, Rickerson E. J Palliat Med; ahead of print. Accessed online on February 15, 2020. DOI: 10.1089/jpm.2019.0427.
In 2002, Soares et al1 reported the use of dexmedetomidine for the treatment of intractable distress in the dying. Later, it was reported that dexmedetomidine was used to facilitate the withdrawal of ventilatory support in palliative care2, as well as for delirium, intractable pain3, and patients with opioid-induced hyperalgesia4.
A new report by Hofherr et al describe eight patients suffering from intractable pain, delirium, or agitation treated with a continuous infusion of 0.1-1.5 mcg/(kg/h) and an optional IV bolus of 0.4-1 mcg/kg for 10 to 30 minutes. The symptoms of these eight patients were improved; distress was reduced and in three cases the opioid dosage was also reduced without withdrawal symptoms.
Dexmedetomidine is an α2-adrenergic agonist with sedative and analgesic properties approved for use in the United States since 1999.
As the authors conclude, more studies are needed in order to explore the use of this medication, which could play an important role in the treatment of patients with severe health-related suffering.
References
Soares LG, Naylor C, Martins MA, Peixoto G. Dexmedetomidine: A new option for intractable distress in the dying. J Pain Symptom Manage 2002; 24(1): 6-8.
Kent CD, Kaufman BS, Lowy J. Dexmedetomidine Facilitates the Withdrawal of Ventilatory Support in Palliative Care. Anesthesiology 2005; 103(2): 439-441.
Hilliard N, Brown S, Mitchinson S. A Case Report of Dexmedetomidine Used to Treat Intractable Pain and Delirium in a Tertiary Palliative Care Unit. Palliat Med 2015; 29(3): 278-281.
Belgrade M, Hall S. Dexmedetomidine Infusion for the Management of Opioid-Induced Hyperalgesia. Pain Med 2010; 11: 1819–1826.
Dexmedetomidine, a selective alpha2agonist, is traditionally used briefly for perioperative anesthesia and sedation of mechanically ventilated patients. Reports of its use in patients with opioid-induced hyperalgesia and intractable pain and delirium suggested it for patients who otherwise may have required palliative sedation to relieve suffering. We present the protocol developed by the interdisciplinary team in our intensive palliative care unit that allows for safe titrated administration without required vital sign monitoring outside the intensive care unit (ICU) (Supplementary Appendix SA1). We describe its efficacy in eight patients who were receiving comfort-focused care.
Do you have any questions regarding Under My Microscope?
Media Watch: Updates
New articles on three MediaWatch topics previously covered by Barry R. Ashpole: family caregivers, GPs, and long-term care.
Family Caregivers
Development and Implementation of the Family Caregiver Decision Guide
Quality Health Research, 2020; 30(2): 303-313. The Guide was designed to address the pressing need for interventions to support family members caring for seriously ill people at home. Family was conceptualized as whoever the ill person accepts as family. The Guide focuses on supporting decision making in planning care for their family member. DOI: 10.1177/1049732319887166.
Home Care and End-of-Life Hospital Admissions: A retrospective interview study in English primary and secondary care
British Journal of General Practice, 2019; 69(685): e561-e569. If policy and practice maintain an emphasis on facilitating deaths at home there must be a concurrent focus on ensuring patients can die there safely. Identifying how best to achieve this will require further research and investment to ensure community nursing provision is adequately staffed, responsive and available 24/7. DOI: 10.3399/bjgp19X704561.
GPs
End-of-life Decision Making by Austrian Physicians: A cross-sectional study
BMC Palliative Care | Online – 4 January 2020 – This study reinforces the recommendation of the Study Commission of the Austrian Federal Chancellery that palliative care in Austria should be extended and that medical, ethical and legal training relating to the treatment of dying patients should be improved. Almost 50% of participates felt insecure when treating end-of-life patients. DOI: 10.1186/s12904-019-0509-3.
Australian GPs’ Perceptions of Barriers and Enablers to Best Practice Palliative Care: A qualitative study
BMC Palliative Care | Online – 31 October 2019 – GPs reported difficulties with the provision of palliative care due to: 1) The complex, often emotional nature of doctor-family-interaction; 2) A lack of evidence to guide care; and, 3) The need to negotiate roles and responsibilities. GPs listed strategies to address their workload and improve communication between healthcare providers. DOI: 10.1186/s12904-019-0478-6.
Long-Term Care
Strategies for the Implementation of Palliative Care Education and Organizational Interventions in Long-Term Care Facilities: A scoping review
Palliative MedicineOnline – 3 February 2020 – Organizational strategies for implementation of palliative care interventions: 1) Facilitation; 2) Education/training; 3) Internal engagement; and, 4) External engagement. Developmental stages comprise: 1) Conditions to introduce the intervention; 2) Embedding the intervention within day-to-day practice; and, 3) Sustaining ongoing change. DOI: 10.1177/0269216319893635.
Palliative Care Nurse Specialists’ Reflections on a Palliative Care Educational Intervention in Long-Term Care: An inductive content analysis
BMC Palliative Care | Online – 19 November 2019 – Supportive Hospice Aged Residential Exchange (SHARE) supports building of a strong relationship between the hospice nurse specialists and facilities, facilitates improved communication between registered nurses and residents and registered nurses and families, and alerts RNs to be vigilant assessing PC needs of residents. DOI: 10.1186/s12904-019-0488-4.
Additional Resource: Special Issue on Palliative and End-of-Life Care in Long-Term Care Nursing Leadership 2019; 32(3)
Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.