Table 4 - uploaded by Lukas Radbruch
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Source publication
The development of palliative medicine in inpatient units in Germany has been impressive in the last years. As a first step of quality assurance, a core documentation form was developed in 1996. In 2001, 55 of the 83 palliative inpatient units in Germany and one unit each in Switzerland and Austria participated in the third phase of the evaluation...
Citations
... Corticosteroids are commonly prescribed in the setting of palliative care, with an estimated prevalence of around one-third to one-half of all patients in palliative care units [1][2][3][4]. Patients receiving corticosteroids in the palliative care setting, especially those with metastatic cancer, can have specific indications such as brain metastases, bone metastases, or spinal cord compression as well as non-specific indications such as fatigue, anorexia, or nausea [5][6][7][8][9][10]. The strength of evidence for each indication varies, but the specific cancer-related indications are better supported than the non-specific indications [11][12][13][14][15][16][17][18]. ...
Purpose
Dexamethasone is a commonly prescribed corticosteroid by both palliative care physicians and radiation oncologists for the treatment of metastatic cancer pain. However, clinical evidence for dexamethasone dose and efficacy is lacking, and prescribing between these different specialties may be influenced by other factors. This study investigates the dexamethasone prescriptions of palliative care physicians and radiation oncologists for cancer pain and their prescription rationales.
Methods
Palliative care physicians and radiation oncologists in British Columbia, Canada, were surveyed on their preferred dexamethasone prescription in response to 4 case vignettes of patients with metastatic cancer and asked to choose a rationale from a list of options which were then categorized as “habit-based,” “results-based,” or “evidence-based.” Response frequencies between the specialties were compared with odds ratios.
Results
The total daily dose and duration of dexamethasone prescriptions were similar between the specialties. Palliative care physicians were significantly more likely than radiation oncologists to prescribe a single daily dose of dexamethasone rather than a divided dose (OR 3.3 [95% CI 2.0–5.5]). This significant difference persisted when separately analyzing results at different total daily doses. Both specialties were more likely to select habit-based rationales rather than evidence-based rationales, with no significant difference between specialties.
Conclusion
These findings show that dexamethasone prescriptions are habit-based and that prescribing habits are different between palliative care physicians and radiation oncologists. Interventions based on these findings could potentially prevent unequal patient care. Further qualitative investigations of physician perceptions are indicated to better understand habit-based corticosteroid prescribing patterns.
... nas unidades de cuidados paliativos. Os fármacos mais utilizados no internamento hospitalar são os analgésicos opióides fortes (68% dos pacientes) e analgésicos puros (59%), além de 19% dos pacientes utilizarem sedativos. Dentre essas drogas, as mais utilizadas, segundo o estudo, foram: dipirona (47% dos pacientes), morfina (42%) e fentanil (28%).(NAUCK. et al, 2004).Já no momento da admissão nas unidades de tratamento, as drogas mais utilizadas foram tramadol e diclofenaco, além da constatação de um aumento de 42% nas prescrições de morfina durante o tratamento. Desta forma, as medicações de última escolha para analgesia de pacientes oncológicos seria a sedação paliativa que consiste na combinação ...
... mais utilizadas foram tramadol e diclofenaco, além da constatação de um aumento de 42% nas prescrições de morfina durante o tratamento. Desta forma, as medicações de última escolha para analgesia de pacientes oncológicos seria a sedação paliativa que consiste na combinação da midazolam (sedativo) associado em 91% dos casos com analgésicos opióides.(NAUCK et al, 2004).As consequências mais comuns provocadas por interações medicamentosas sãodelirium, parkinsonismo induzido por drogas, acatisia, síndrome da serotonina e síndrome maligna dos neurolépticos, sendo que muitos desses sintomas são erroneamente Brazilian Journal of Development, Curitiba, v.7, n.9, p. 86975-86988 sep. 2021 atribuídos à condiçã ...
... Two studies were multinational, involving three and 12 countries, respectively. 56,58 Studies were primarily conducted across hospice settings (n = 16) and dedicated palliative care centers, units, and/or services (n = 22). Other settings included general practice (n = 1), hospitals (n = 12), nursing homes (n = 3) and long-term care facilities (n = 1). ...
Background
Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs.
Objective(s)
To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care.
Methods
A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis.
Results
Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events.
Conclusions
This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.
... Based on expert views, PC organizations and agencies have identified or created lists of important medicines for PC [5][6][7]. The WHO has created a Model List of Essential Medicines (EML), which is revised every two years and is dependent on each medicine's reliability, efficacy, and cost-effectiveness [8,9]. In response to the Saudi Health Council (SHC) request, an expert palliative multidisciplinary central committee was formulated to develop a model of Saudi essential palliative medication lists (EML) to be updated every 2 years, based on the WHO criteria of EML (the safety, efficacy and cost-effectiveness of each medicine listed) [9]. ...
In response to the request of the Saudi Health Council, an expert palliative multi-disciplinary central committee was created to develop a model of the essential Saudi palliative medication list (EML), to be updated every 2 years, based on the World Health Organization (WHO) criteria for EML.
Objectives: Our aim was to explore the degree of consensus among physicians
involved in palliative care (PC) regarding appropriate pharmacological treatment for
common symptoms of palliative patients with cancer and to thus develop a national
medication list of essential medicines for PC based on expert opinion. This list will serve
as a key for future decision making in clinical practice.
Methods: We conducted a descriptive cross-sectional study of all consultants from
July 2020 to August 2020. A structured questionnaire was used to collect the data, which were analyzed using Statistical Package for the Social Sciences (SPSS) version 25.
Results: The top palliative consultant experts in the Kingdom of Saudi Arabia participated in the study, with a high level of consensus among the experts. More than 60 medications were included in the review. The survey influenced the PC medication list following consensus. The preference for a medication was grouped into three categories—mandatory, necessary, and optional—based on administration frequency and the specified categories. The “mandatory” medications such as baclofen tablets, loperamide, ibuprofen tablets, midazolam injections, Tylenol III and fentanyl injections, morphine injections, morphine (IR) syrup, and morphine (SR) tablets were considered.
The “necessary” medications such as modafinil tablets, morphine (SR) 60 mg, megestrol, and prednisone were considered. The “optional” medications included the following:
fentanyl 500 mcg injections, hydrocortisone cream, and atropine eye drops.
Conclusions: The drugs prescribed and reported in this survey can be incorporated
with the WHO EML, which in turn can lead to a constructive change in local drug policies
and provide a basis for the minimum standard of care for PC institutions.
... P olypharmacy is a significant and increasingly common problem in palliative care. [1][2][3][4] In patients receiving palliative care, it is associated with reduced quality of life, 5,6 adherence to medicines, 1 and drug-drug interactions. 7 Palliative patients find the number of prescribed medicines burdensome and frequently wish to take fewer. ...
Background:
Lack of guidance is highlighted as a barrier to deprescribing in palliative care. Two deprescribing tools exist, but with inclusion and exclusion criteria that limit utility. The tools have not previously been compared directly or used in an unselected palliative population.
Objective:
To compare the OncPal and STOPPFrail deprescribing tools to an expert review in an unselected palliative population. Secondary aims included a description of medicines incorrectly classified by both tools.
Design:
Fifty palliative inpatients were retrospectively reviewed by an expert panel, and both tools were independently applied to the patients. Positive and negative predictive values (PPV and NPV) were calculated per patient using the expert review as the gold standard.
Results:
The median number of medicines per patient was 11, with 19% of medicines deemed inappropriate. The PPV and NPV were 75% (interquartile range 50-100) and 91% (interquartile range 84-100), respectively, for OncPal, and 100% (interquartile range 50-100) and 90% (interquartile range 78-100), respectively, for STOPPFrail. There was no statistically significant difference between the tools (PPV p = 0.42 and NPV p = 0.07). The main medicines incorrectly ceased by OncPal were antianginals for stable coronary artery disease, and haloperidol for nausea by STOPPFrail.
Conclusion:
There was no significant difference between the tools. Both tools performed well in an unselected population. Some minor amendments could improve the PPV of both tools.
... Treatment Five treatments were initiated/changed in more than 10% of patients (olanzapine, corticosteroids, laxatives, metoclopramide, and domperidone) but no clear relationship between the degree of nausea and choice of treatment was observed except for olanzapine which was initiated in only a single patient with "a little" nausea. Other studies have demonstrated that metoclopramide was the preferred treatment choice followed by haloperidol among Australian doctors [31] and a German study showed that antiemetics were prescribed for 27% of 1304 inpatients from palliative care units [32]. Twenty-one percent of all patients received metoclopramide while haloperidol was prescribed for 13% of patients. ...
Background
The prevalence of nausea/vomiting in patients with advanced cancer has a wide range. Due to a very low level of evidence regarding antiemetic treatment, current guidelines recommend an etiology-based approach. The evidence for this approach is also slim and research is urgently needed.
Objectives
(Part One) to elucidate the prevalence of nausea and the possible associations with sociodemographic and clinical variables and (Part Two) to investigate possible etiologies of nausea and antiemetic treatments initiated in patients with nausea.
Methods
Patients with advanced cancer and no recent antineoplastic treatment were included in a prospective two-part study. In Part One, patients completed an extended version of the EORTC QLQ-C15-PAL. Nauseated patients could then be included in Part Two in which possible etiologies and antiemetic treatment were recorded and a follow-up questionnaire was completed.
Results
Eight hundred twenty-one patients were included and 46% reported any degree of nausea. Younger age and female sex were associated with a higher degree of nausea. Common etiologies included constipation, opioid use, and “other,” and treatments associated with a statistically significant decrease in nausea/vomiting were olanzapine, laxatives, corticosteroids, domperidone, and metoclopramide.
Conclusion
Nausea was a common symptom in this patient population and many different etiologies were suggested. Most patients reported a lower degree of nausea at follow-up. More research in treatment approaches and specific antiemetics is strongly needed.
... The reason for high consumption of preventive drugs in the aforementioned study was stated to be the lack of coordination between the healthcare service providers in the primary and secondary levels. Moreover, other studies identified opioids, psychoactive drugs (Kierner et al., 2016), morphine and other painkillers, as well as antiemetic drugs (Nauck et al., 2004) as the most frequently-used medications in the patients with advanced cancer. ...
Background
Polypharmacy is defined as the concurrent use of more than four or five medications by an individual. The prevalence of this condition has increased due to the ageing population and the related illnesses. Use of multiple medications would increase the risk of side-effects, drug interactions, and medical costs. The present study aimed to determine the frequency of polypharmacy in the advanced cancer patients.
Methods
In this cross-sectional study, 92 patients with advanced cancer were selected through convenience sampling from the inpatients and outpatients who referred to the Palliative Care Unit of Imam Khomeini Hospital (Tehran) in 2017. An examining physician completed a researcher-made checklist for all the subjects based on the patients’ biography and medical records. Statistical analysis was performed by using SPSS software (version 19.0) through descriptive and analytical tests at the significance level of p<0.05.
Results
The participants’ mean age was 55.5±16.2 years. A minimum of one comorbid disease was seen in 81.5% of the patients (n=75), the most prevalent of which were psychiatric disorders. Eighty-eight percent of the patients (n=81) were on at least 5 or more medications. Opioids and antacids were the most common medications used by these patients.
Conclusion
The frequency of polypharmacy and average number of consumed medications were high in patients with advanced cancer. Studying the effectiveness of these medications can highly help the physicians stop or continue prescribing such medications, and guide the focus of attention towards the drugs that can improve the patients’ quality of life in the final days.
... Corticosteroids are used in the treatment of a wide variety of diseases. In the field of palliative care, corticosteroids are frequently prescribed to alleviate distressing symptoms in patients with advanced cancer, including anorexia, fatigue, and pain [1][2][3]. However, corticosteroids are associated with several side effects: susceptibility to infection, hyperglycemia, insulin resistance, proximal myopathy and catabolic effects, skin changes, and adrenal insufficiency [4]. ...
Purpose:
Corticosteroids are commonly used in palliative care settings, but are associated with several side effects. Although adverse events (AEs) are highly distressing for patients, few data are available from prospective studies to look at incidence or predictors of such harms. The aim of this study is to identify AE reporting among studies of patients with advanced cancer receiving corticosteroids for any reason.
Methods:
A systematic review was conducted using the following data sources: PubMed, Medline, SCOPUS, Cochrane reviews, and CINAHL. Randomized controlled trials (RCTs) with patients with advanced cancer assessing the effect of corticosteroids were included. Consecutive cohort observational studies of corticosteroid toxicities in cancer patients were also included.
Results:
Twenty-seven RCTs and 12 consecutive cohort observational studies were identified. The most frequently reported primary outcome of RCTs was nausea and vomiting (8/27). Dexamethasone was prescribed in almost half of RCTs (13/27). In consecutive cohort studies, the primary outcomes were a wide variety of symptoms. Dexamethasone was also the most common glucocorticoid used (7/12). In terms of quality of AE reporting, two RCTs and one consecutive cohort study used a validated AE assessment tool in their studies.
Conclusions:
Side effects of corticosteroids in advanced cancer patients were poorly reported with few data using validated tools. Researchers should be aware of the guideline of AE reporting to provide the best evidence of risk-benefit balance. Developing specific consensus guidelines about AE reporting in studies of glucocorticoids in studies of people with advanced cancer would be useful.
... The World Health Organization has created a summary of essential medicines in palliative care for the pharmacotherapy of the most common symptoms: anorexia and fatigue, anxiety, constipation, delirium, depression, diarrhoea, pain, dyspnoea, nausea and vomiting, and respiratory secretions. 1 Masman et al. listed top 10 drugs used in the end-of-life care in a palliative care centre, 2 while Nauck et al. described drugs used in German palliative care. 3 According to literature, morphine, fentanyl, tramadol, metoclopramide, hyoscine butylbromide, haloperidol, levomepromazine, midazolam and clonazepam are among the most commonly used medicines in palliative patients, especially during the end-of-life care. [1][2][3][4][5][6] Studies on drugs and their influence on people include their determination in body fluids as well as identification and determination of their metabolites. ...
... 3 According to literature, morphine, fentanyl, tramadol, metoclopramide, hyoscine butylbromide, haloperidol, levomepromazine, midazolam and clonazepam are among the most commonly used medicines in palliative patients, especially during the end-of-life care. [1][2][3][4][5][6] Studies on drugs and their influence on people include their determination in body fluids as well as identification and determination of their metabolites. Triple quadrupole mass spectrometers due to their wide dynamic linear range and high selectivity in multiple reaction monitoring mode are extensively used for quantitative purposes including the determination of the palliative care drugs. ...
The results of research on selected drugs used in palliative care are presented, including fentanyl, tramadol, metoclopramide, hyoscine butylbromide, midazolam, haloperidol, levomepromazine and clonazepam. Interpretation of their ESI mass spectra obtained by the use of a triple quadrupole linear ion trap mass spectrometer is given. As a result, fragmentation pathways described in the literature are complemented and presented with more details. On their basis, transitions for quantitative analysis are selected and chromatographic conditions for the determination of the palliative care drugs are proposed as well. These results enable future studies on palliative care drugs in elderly patients including both their quantitation in body fluids and easier identification of their metabolites.
... Current guidelines 84 on the use of non-opioids in palliative medicine are mainly based on studies dealing with cancer pain due to a complete lack of evidence regarding other disease entities. Additionally, empirical evidence on the efficacy of non-opioids is not adequately mirrored in clinical guidelines claiming international validity, for example, dipyrone not being listed as essential medicine in palliative care, 84,85 as well as clinical practice, for example, acetaminophen being the most prescribed analgesic in palliative patients in the USA. 86 With regard to cancer pain particularly, the efficacy of non-opioids in cancer-related pain of different aetiologies remains unanswered. ...
Non‐opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence‐based recommendations addressing the efficacy, tolerability, and safety of non‐opioids in this field. A comprehensive systematic review and meta‐analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non‐opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid‐sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta‐analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non‐steroidal anti‐inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non‐opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized‐controlled studies on the use of non‐opioids in a wide range of end‐stage diseases except for cancer. Non‐steroidal anti‐inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long‐term use. There is a lack of evidence regarding pain treatment by non‐opioids in specific cancer entities.
