Patient & Survivor Care

Use of all glucocorticoids is associated with a two- to threefold increased risk of venous thromboembolism, depending on the type of glucocorticoid, the route of administration, and other factors, according to a report published online April 1 in JAMA Internal Medicine.

Systemic glucocorticoids, as compared with inhaled ones or glucocorticoids that act on the intestines, were associated with the highest risk of VTE. New use was linked to higher risk than continuing or past use, and the VTE risk increased as the dose of glucocorticoids increased, said Sigrun A. Johannesdottir of the department of clinical epidemiology, Aarhus (the Netherlands) University Hospital, and her associates.

These findings are from a population-based case-control study, which cannot prove a cause-and-effect relationship. Moreover, it is difficult to statistically account for all the confounding effects of patients’ underlying disease – the reason they were taking glucocorticoids in the first place – because such disorders raise the risk of VTE directly or cause immobility that in turn can lead to VTE.

However, the timing of this adverse effect, the strength of the association across all types of glucocorticoids, and the fact that the association persisted after the data were adjusted to account for multiple confounders all "increase our confidence that the results reflect a true biological effect," the investigators said.

"Clinicians should be aware of this association," they noted.

Ms. Johannesdottir and her colleagues used data from several Danish national medical registries to identify all adults who were diagnosed with VTE in Denmark in 2005-2012, all patients who filled prescriptions for glucocorticoids during the study period, and all indications for the drugs as well as all relevant comorbidities. They matched 10 control subjects for age and sex from the general population to each study subject.

A total of 38,765 VTE cases and 387,650 controls were included in this study. The median age was 67 years, and slightly more than half of those studied were women.

All glucocorticoid users were found to be at increased risk for VTE, particularly for pulmonary embolism, compared with nonusers, the researchers said.

Systemic glucocorticoids, including betamethasone, methylprednisolone, prednisolone, prednisone, triamcinolone, and hydrocortisone, raised VTE risk to the highest degree. (No patients filled prescriptions for dexamethasone in this study.)

Inhaled corticosteroids and corticosteroids that act on the intestines also raised VTE risk significantly. Among the systemic glucocorticoids, prednisolone and prednisone raised VTE risk the most.

New use of glucocorticoids was associated with the highest risk of VTE, but current use, continuing use, and former use also raised the risk significantly. Oral formulations were associated with the highest risk of VTE, but injectable formulations also raised the risk significantly, Ms. Johannesdottir and her associates reported (JAMA Intern. Med. 2013 April 1 [doi:10.1001/jamainternmed.2013.122]).

In particular, new use of systemic glucocorticoids was associated with the highest risk for VTE, with an estimated incidence rate ratio of 3.06, compared with nonuse of glucocorticoids.

The risk of VTE also rose with increasing cumulative doses of all glucocorticoids.

In further analyses, elevated risk for VTE persisted across all the subgroups that were examined.

The findings did not change appreciably in a sensitivity analysis that included only subjects who took glucocorticoids for at least 5 years.

"The temporality of the association (i.e., the strongest effect at initiation of therapy and the absence of an effect after discontinuation) is in line with an effect on coagulation," Ms. Johannesdottir and her associates said.

This study was supported by the Clinical Epidemiological Research Foundation at Aarhus University Hospital. No relevant conflicts of interest were reported.

Use of all glucocorticoids is associated with a two- to threefold increased risk of venous thromboembolism, depending on the type of glucocorticoid, the route of administration, and other factors, according to a report published online April 1 in JAMA Internal Medicine.

Systemic glucocorticoids, as compared with inhaled ones or glucocorticoids that act on the intestines, were associated with the highest risk of VTE. New use was linked to higher risk than continuing or past use, and the VTE risk increased as the dose of glucocorticoids increased, said Sigrun A. Johannesdottir of the department of clinical epidemiology, Aarhus (the Netherlands) University Hospital, and her associates.

These findings are from a population-based case-control study, which cannot prove a cause-and-effect relationship. Moreover, it is difficult to statistically account for all the confounding effects of patients’ underlying disease – the reason they were taking glucocorticoids in the first place – because such disorders raise the risk of VTE directly or cause immobility that in turn can lead to VTE.

However, the timing of this adverse effect, the strength of the association across all types of glucocorticoids, and the fact that the association persisted after the data were adjusted to account for multiple confounders all "increase our confidence that the results reflect a true biological effect," the investigators said.

"Clinicians should be aware of this association," they noted.

Ms. Johannesdottir and her colleagues used data from several Danish national medical registries to identify all adults who were diagnosed with VTE in Denmark in 2005-2012, all patients who filled prescriptions for glucocorticoids during the study period, and all indications for the drugs as well as all relevant comorbidities. They matched 10 control subjects for age and sex from the general population to each study subject.

A total of 38,765 VTE cases and 387,650 controls were included in this study. The median age was 67 years, and slightly more than half of those studied were women.

All glucocorticoid users were found to be at increased risk for VTE, particularly for pulmonary embolism, compared with nonusers, the researchers said.

Systemic glucocorticoids, including betamethasone, methylprednisolone, prednisolone, prednisone, triamcinolone, and hydrocortisone, raised VTE risk to the highest degree. (No patients filled prescriptions for dexamethasone in this study.)

Inhaled corticosteroids and corticosteroids that act on the intestines also raised VTE risk significantly. Among the systemic glucocorticoids, prednisolone and prednisone raised VTE risk the most.

New use of glucocorticoids was associated with the highest risk of VTE, but current use, continuing use, and former use also raised the risk significantly. Oral formulations were associated with the highest risk of VTE, but injectable formulations also raised the risk significantly, Ms. Johannesdottir and her associates reported (JAMA Intern. Med. 2013 April 1 [doi:10.1001/jamainternmed.2013.122]).

In particular, new use of systemic glucocorticoids was associated with the highest risk for VTE, with an estimated incidence rate ratio of 3.06, compared with nonuse of glucocorticoids.

The risk of VTE also rose with increasing cumulative doses of all glucocorticoids.

In further analyses, elevated risk for VTE persisted across all the subgroups that were examined.

The findings did not change appreciably in a sensitivity analysis that included only subjects who took glucocorticoids for at least 5 years.

"The temporality of the association (i.e., the strongest effect at initiation of therapy and the absence of an effect after discontinuation) is in line with an effect on coagulation," Ms. Johannesdottir and her associates said.

This study was supported by the Clinical Epidemiological Research Foundation at Aarhus University Hospital. No relevant conflicts of interest were reported.

Use of all glucocorticoids is associated with a two- to threefold increased risk of venous thromboembolism, depending on the type of glucocorticoid, the route of administration, and other factors, according to a report published online April 1 in JAMA Internal Medicine.

Systemic glucocorticoids, as compared with inhaled ones or glucocorticoids that act on the intestines, were associated with the highest risk of VTE. New use was linked to higher risk than continuing or past use, and the VTE risk increased as the dose of glucocorticoids increased, said Sigrun A. Johannesdottir of the department of clinical epidemiology, Aarhus (the Netherlands) University Hospital, and her associates.

These findings are from a population-based case-control study, which cannot prove a cause-and-effect relationship. Moreover, it is difficult to statistically account for all the confounding effects of patients’ underlying disease – the reason they were taking glucocorticoids in the first place – because such disorders raise the risk of VTE directly or cause immobility that in turn can lead to VTE.

However, the timing of this adverse effect, the strength of the association across all types of glucocorticoids, and the fact that the association persisted after the data were adjusted to account for multiple confounders all "increase our confidence that the results reflect a true biological effect," the investigators said.

"Clinicians should be aware of this association," they noted.

Ms. Johannesdottir and her colleagues used data from several Danish national medical registries to identify all adults who were diagnosed with VTE in Denmark in 2005-2012, all patients who filled prescriptions for glucocorticoids during the study period, and all indications for the drugs as well as all relevant comorbidities. They matched 10 control subjects for age and sex from the general population to each study subject.

A total of 38,765 VTE cases and 387,650 controls were included in this study. The median age was 67 years, and slightly more than half of those studied were women.

All glucocorticoid users were found to be at increased risk for VTE, particularly for pulmonary embolism, compared with nonusers, the researchers said.

Systemic glucocorticoids, including betamethasone, methylprednisolone, prednisolone, prednisone, triamcinolone, and hydrocortisone, raised VTE risk to the highest degree. (No patients filled prescriptions for dexamethasone in this study.)

Inhaled corticosteroids and corticosteroids that act on the intestines also raised VTE risk significantly. Among the systemic glucocorticoids, prednisolone and prednisone raised VTE risk the most.

New use of glucocorticoids was associated with the highest risk of VTE, but current use, continuing use, and former use also raised the risk significantly. Oral formulations were associated with the highest risk of VTE, but injectable formulations also raised the risk significantly, Ms. Johannesdottir and her associates reported (JAMA Intern. Med. 2013 April 1 [doi:10.1001/jamainternmed.2013.122]).

In particular, new use of systemic glucocorticoids was associated with the highest risk for VTE, with an estimated incidence rate ratio of 3.06, compared with nonuse of glucocorticoids.

The risk of VTE also rose with increasing cumulative doses of all glucocorticoids.

In further analyses, elevated risk for VTE persisted across all the subgroups that were examined.

The findings did not change appreciably in a sensitivity analysis that included only subjects who took glucocorticoids for at least 5 years.

"The temporality of the association (i.e., the strongest effect at initiation of therapy and the absence of an effect after discontinuation) is in line with an effect on coagulation," Ms. Johannesdottir and her associates said.

This study was supported by the Clinical Epidemiological Research Foundation at Aarhus University Hospital. No relevant conflicts of interest were reported.

NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.

Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.

"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."

Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.

Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.

Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).

Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.

As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.

"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.

"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."

The authors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.

Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.

"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."

Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.

Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.

Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).

Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.

As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.

"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.

"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."

The authors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.

Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.

"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."

Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.

Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.

Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).

Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.

As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.

"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.

"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."

The authors reported having no financial disclosures.

[email protected]

NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.

The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.

To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).

Patrice Wendling/IMNG Medical Media

A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.

In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.

Thus, sensitivity was 90% and specificity 91%.

Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.

Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.

"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.

E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.

Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.

"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."

As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.

During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.

Ms. Gavinski and her coauthors reported no relevant disclosures.

[email protected]

NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.

The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.

To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).

Patrice Wendling/IMNG Medical Media

A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.

In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.

Thus, sensitivity was 90% and specificity 91%.

Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.

Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.

"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.

E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.

Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.

"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."

As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.

During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.

Ms. Gavinski and her coauthors reported no relevant disclosures.

[email protected]

NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.

The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.

To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).

Patrice Wendling/IMNG Medical Media

A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.

In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.

Thus, sensitivity was 90% and specificity 91%.

Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.

Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.

"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.

E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.

Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.

"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."

As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.

During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.

Ms. Gavinski and her coauthors reported no relevant disclosures.

[email protected]

NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.

The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.

Patrice Wendling/IMNG Medical Media

Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.

This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.

"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.

In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.

The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.

Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.

She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.

The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.

"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.

The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.

Patrice Wendling/IMNG Medical Media

"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.

The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.

During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.

"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.

"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."

The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.

NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.

The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.

Patrice Wendling/IMNG Medical Media

Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.

This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.

"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.

In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.

The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.

Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.

She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.

The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.

"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.

The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.

Patrice Wendling/IMNG Medical Media

"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.

The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.

During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.

"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.

"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."

The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.

NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.

The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.

Patrice Wendling/IMNG Medical Media

Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.

This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.

"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.

In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.

The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.

Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.

She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.

The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.

"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.

The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.

Patrice Wendling/IMNG Medical Media

"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.

The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.

During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.

"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.

Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.

"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."

The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.

An oral three-drug regimen of aprepitant, a 5HT₃ antagonist, and dexamethasone is reasonable and necessary immediately before and within 48 hours after moderately emetogenic chemotherapy is administered to Medicare beneficiaries, the Centers for Medicare and Medicaid Services stated in a proposed decision memo.  

This regimen would be covered when it is administered in that time frame with any of the following chemotherapeutic agents, administered either singularly or in combination: alemtuzumab, azacitidine, bendamustine, carboplatin, carmustine, cisplatin, clofarabine, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan, lomustine, mechlorethamine, oxaliplatin, and streptozocin, according to the CMS. 

The proposal would expand coverage of the three-drug regimen to include its use with additional chemotherapy drugs that are not currently covered, including alemtuzumab, azacitidine, bendamustine, carboplatin, clofarabine, cytarabine, daunorubicin, idarubicin, ifosfamide, irinotecan and oxaliplatin.

CMS defines moderately emetogenic chemotherapy as any anticancer agents so designated in at least two of three guidelines published by the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO)/Multinational Association of Supportive Care in Cancer (MASCC). 

According to the CMS, 70%-80% of all patients receiving chemotherapy experience nausea and vomiting. Chemotherapy induced emesis can impair quality of life, as well as cause dehydration, malnutrition, fatigue, confusion, electrolyte imbalance, esophageal tears and aspiration pneumonia. Further, poor control of the emesis can interrupt or force withdrawal from critical chemotherapy.

"We are mindful of the relatively minimal risks of the three-drug antiemetic regimen; the severe consequences that can occur if chemotherapy is delayed or halted altogether because of emesis; and the frequency with which new anticancer chemotherapeutic agents appear.  We also recognize that the available classification schemes for chemotherapy emetogenicity may evolve as evidence continues to be developed on this problem," CMS officials stated in their proposed decision memo.

They also proposed that Medicare Administrative Contractors be allowed to determine coverage for an oral three-drug antiemesis regimen of aprepitant, a 5HT₃ antagonist and dexamethasone with other anticancer chemotherapeutic agents that are FDA approved and are defined as highly or moderately emetogenic in at least two of three guidelines from NCCN, ASCO, and ESMO)/MASCC.

The CMS is seeking comments on the proposal, especially in regard to whether the term “NK-1 antagonists” should be used in its coverage manual. Aprepitant is currently the sole NK-1 antagonist component of the three drug antiemetic regimen.  The CMS will respond to public comments in a final decision memorandum.

An oral three-drug regimen of aprepitant, a 5HT₃ antagonist, and dexamethasone is reasonable and necessary immediately before and within 48 hours after moderately emetogenic chemotherapy is administered to Medicare beneficiaries, the Centers for Medicare and Medicaid Services stated in a proposed decision memo.  

This regimen would be covered when it is administered in that time frame with any of the following chemotherapeutic agents, administered either singularly or in combination: alemtuzumab, azacitidine, bendamustine, carboplatin, carmustine, cisplatin, clofarabine, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan, lomustine, mechlorethamine, oxaliplatin, and streptozocin, according to the CMS. 

The proposal would expand coverage of the three-drug regimen to include its use with additional chemotherapy drugs that are not currently covered, including alemtuzumab, azacitidine, bendamustine, carboplatin, clofarabine, cytarabine, daunorubicin, idarubicin, ifosfamide, irinotecan and oxaliplatin.

CMS defines moderately emetogenic chemotherapy as any anticancer agents so designated in at least two of three guidelines published by the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO)/Multinational Association of Supportive Care in Cancer (MASCC). 

According to the CMS, 70%-80% of all patients receiving chemotherapy experience nausea and vomiting. Chemotherapy induced emesis can impair quality of life, as well as cause dehydration, malnutrition, fatigue, confusion, electrolyte imbalance, esophageal tears and aspiration pneumonia. Further, poor control of the emesis can interrupt or force withdrawal from critical chemotherapy.

"We are mindful of the relatively minimal risks of the three-drug antiemetic regimen; the severe consequences that can occur if chemotherapy is delayed or halted altogether because of emesis; and the frequency with which new anticancer chemotherapeutic agents appear.  We also recognize that the available classification schemes for chemotherapy emetogenicity may evolve as evidence continues to be developed on this problem," CMS officials stated in their proposed decision memo.

They also proposed that Medicare Administrative Contractors be allowed to determine coverage for an oral three-drug antiemesis regimen of aprepitant, a 5HT₃ antagonist and dexamethasone with other anticancer chemotherapeutic agents that are FDA approved and are defined as highly or moderately emetogenic in at least two of three guidelines from NCCN, ASCO, and ESMO)/MASCC.

The CMS is seeking comments on the proposal, especially in regard to whether the term “NK-1 antagonists” should be used in its coverage manual. Aprepitant is currently the sole NK-1 antagonist component of the three drug antiemetic regimen.  The CMS will respond to public comments in a final decision memorandum.

An oral three-drug regimen of aprepitant, a 5HT₃ antagonist, and dexamethasone is reasonable and necessary immediately before and within 48 hours after moderately emetogenic chemotherapy is administered to Medicare beneficiaries, the Centers for Medicare and Medicaid Services stated in a proposed decision memo.  

This regimen would be covered when it is administered in that time frame with any of the following chemotherapeutic agents, administered either singularly or in combination: alemtuzumab, azacitidine, bendamustine, carboplatin, carmustine, cisplatin, clofarabine, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan, lomustine, mechlorethamine, oxaliplatin, and streptozocin, according to the CMS. 

The proposal would expand coverage of the three-drug regimen to include its use with additional chemotherapy drugs that are not currently covered, including alemtuzumab, azacitidine, bendamustine, carboplatin, clofarabine, cytarabine, daunorubicin, idarubicin, ifosfamide, irinotecan and oxaliplatin.

CMS defines moderately emetogenic chemotherapy as any anticancer agents so designated in at least two of three guidelines published by the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO)/Multinational Association of Supportive Care in Cancer (MASCC). 

According to the CMS, 70%-80% of all patients receiving chemotherapy experience nausea and vomiting. Chemotherapy induced emesis can impair quality of life, as well as cause dehydration, malnutrition, fatigue, confusion, electrolyte imbalance, esophageal tears and aspiration pneumonia. Further, poor control of the emesis can interrupt or force withdrawal from critical chemotherapy.

"We are mindful of the relatively minimal risks of the three-drug antiemetic regimen; the severe consequences that can occur if chemotherapy is delayed or halted altogether because of emesis; and the frequency with which new anticancer chemotherapeutic agents appear.  We also recognize that the available classification schemes for chemotherapy emetogenicity may evolve as evidence continues to be developed on this problem," CMS officials stated in their proposed decision memo.

They also proposed that Medicare Administrative Contractors be allowed to determine coverage for an oral three-drug antiemesis regimen of aprepitant, a 5HT₃ antagonist and dexamethasone with other anticancer chemotherapeutic agents that are FDA approved and are defined as highly or moderately emetogenic in at least two of three guidelines from NCCN, ASCO, and ESMO)/MASCC.

The CMS is seeking comments on the proposal, especially in regard to whether the term “NK-1 antagonists” should be used in its coverage manual. Aprepitant is currently the sole NK-1 antagonist component of the three drug antiemetic regimen.  The CMS will respond to public comments in a final decision memorandum.

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

LAS VEGAS – Hypoactive delirium is common in terminally ill patients; just as disconcerting as hyperactive, agitated delirium; and just as likely to respond to antipsychotics, according to Dr. William Breitbart, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center, New York.

Outwardly, patients with hypoactive delirium appear less distressed than do patients with hyperactive delirium, yet they report just as much distress and about half of them report delusions and hallucinations.

About 80% of terminal cancer patients become delirious in their final weeks of life, and about half of them experience hypoactive delirium in association with opioid analgesia, metabolic derangements, and organ failure.

Addressing hypoactive delirium requires diplomacy, especially in patients with hallucinations, he said. Dying patients often see dead relatives – parents, for instance, who come to accompany them to the afterlife. "For me to barrel into the room and say those are psychotic symptoms or describe these experiences as absurd would be insensitive; they are profoundly meaningful experiences to patients and families," Dr. Breitbart said at the annual psychopharmacology update held by the Nevada Psychiatric Association. Instead, he acknowledges the significance of the visions, but notes that they can rapidly change to very frightening visions. He then discusses the use of medications to avert this possible progression.

Antipsychotics help to reduce agitation, psychotic symptoms, and more subtle problems such as disorientation in these patients, Dr. Breitbart said at the conference. When the underlying metabolic problems can be addressed in cancer patients, the drugs can be used for a few weeks and this sort of short-term use is not associated with increased mortality, he said. The ultimate goal of treatment is an "upright patient who is awake, alert, and conversant with family and staff."

In the patient with imminent terminal illness, however, sometimes "the best you can achieve (with antipsychotics) is a sedated patient," he said.

Low-dose haloperidol is generally preferred; atypical antipsychotics have not proven any more effective or safer. Close monitoring for side effects – particularly prolonged QTc intervals and extrapyramidal symptoms – is essential (J. Clin. Oncol. 2012;30:1206-14).

Haloperidol and chlorpromazine work equally well in both types of delirium. Dr. Breitbart said he’ll sometimes add chlorpromazine when agitation fails to respond to haloperidol alone.

Aripiprazole may work a bit better in hypoactive patients; olanzapine may be preferred in hyperactive patients. Risperidone is another option.

"We tend not to use benzodiazepines because they worsen delirium, but if your goal is to sedate a patient, then benzodiazepines are helpful. We often use haloperidol in combination with a drug like lorazepam to help get an agitated patient under better control," he said.

Dr. Breitbart said he has no relevant financial relationships with commercial interests.

[email protected]

LAS VEGAS – Hypoactive delirium is common in terminally ill patients; just as disconcerting as hyperactive, agitated delirium; and just as likely to respond to antipsychotics, according to Dr. William Breitbart, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center, New York.

Outwardly, patients with hypoactive delirium appear less distressed than do patients with hyperactive delirium, yet they report just as much distress and about half of them report delusions and hallucinations.

About 80% of terminal cancer patients become delirious in their final weeks of life, and about half of them experience hypoactive delirium in association with opioid analgesia, metabolic derangements, and organ failure.

Addressing hypoactive delirium requires diplomacy, especially in patients with hallucinations, he said. Dying patients often see dead relatives – parents, for instance, who come to accompany them to the afterlife. "For me to barrel into the room and say those are psychotic symptoms or describe these experiences as absurd would be insensitive; they are profoundly meaningful experiences to patients and families," Dr. Breitbart said at the annual psychopharmacology update held by the Nevada Psychiatric Association. Instead, he acknowledges the significance of the visions, but notes that they can rapidly change to very frightening visions. He then discusses the use of medications to avert this possible progression.

Antipsychotics help to reduce agitation, psychotic symptoms, and more subtle problems such as disorientation in these patients, Dr. Breitbart said at the conference. When the underlying metabolic problems can be addressed in cancer patients, the drugs can be used for a few weeks and this sort of short-term use is not associated with increased mortality, he said. The ultimate goal of treatment is an "upright patient who is awake, alert, and conversant with family and staff."

In the patient with imminent terminal illness, however, sometimes "the best you can achieve (with antipsychotics) is a sedated patient," he said.

Low-dose haloperidol is generally preferred; atypical antipsychotics have not proven any more effective or safer. Close monitoring for side effects – particularly prolonged QTc intervals and extrapyramidal symptoms – is essential (J. Clin. Oncol. 2012;30:1206-14).

Haloperidol and chlorpromazine work equally well in both types of delirium. Dr. Breitbart said he’ll sometimes add chlorpromazine when agitation fails to respond to haloperidol alone.

Aripiprazole may work a bit better in hypoactive patients; olanzapine may be preferred in hyperactive patients. Risperidone is another option.

"We tend not to use benzodiazepines because they worsen delirium, but if your goal is to sedate a patient, then benzodiazepines are helpful. We often use haloperidol in combination with a drug like lorazepam to help get an agitated patient under better control," he said.

Dr. Breitbart said he has no relevant financial relationships with commercial interests.

[email protected]

LAS VEGAS – Hypoactive delirium is common in terminally ill patients; just as disconcerting as hyperactive, agitated delirium; and just as likely to respond to antipsychotics, according to Dr. William Breitbart, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center, New York.

Outwardly, patients with hypoactive delirium appear less distressed than do patients with hyperactive delirium, yet they report just as much distress and about half of them report delusions and hallucinations.

About 80% of terminal cancer patients become delirious in their final weeks of life, and about half of them experience hypoactive delirium in association with opioid analgesia, metabolic derangements, and organ failure.

Addressing hypoactive delirium requires diplomacy, especially in patients with hallucinations, he said. Dying patients often see dead relatives – parents, for instance, who come to accompany them to the afterlife. "For me to barrel into the room and say those are psychotic symptoms or describe these experiences as absurd would be insensitive; they are profoundly meaningful experiences to patients and families," Dr. Breitbart said at the annual psychopharmacology update held by the Nevada Psychiatric Association. Instead, he acknowledges the significance of the visions, but notes that they can rapidly change to very frightening visions. He then discusses the use of medications to avert this possible progression.

Antipsychotics help to reduce agitation, psychotic symptoms, and more subtle problems such as disorientation in these patients, Dr. Breitbart said at the conference. When the underlying metabolic problems can be addressed in cancer patients, the drugs can be used for a few weeks and this sort of short-term use is not associated with increased mortality, he said. The ultimate goal of treatment is an "upright patient who is awake, alert, and conversant with family and staff."

In the patient with imminent terminal illness, however, sometimes "the best you can achieve (with antipsychotics) is a sedated patient," he said.

Low-dose haloperidol is generally preferred; atypical antipsychotics have not proven any more effective or safer. Close monitoring for side effects – particularly prolonged QTc intervals and extrapyramidal symptoms – is essential (J. Clin. Oncol. 2012;30:1206-14).

Haloperidol and chlorpromazine work equally well in both types of delirium. Dr. Breitbart said he’ll sometimes add chlorpromazine when agitation fails to respond to haloperidol alone.

Aripiprazole may work a bit better in hypoactive patients; olanzapine may be preferred in hyperactive patients. Risperidone is another option.

"We tend not to use benzodiazepines because they worsen delirium, but if your goal is to sedate a patient, then benzodiazepines are helpful. We often use haloperidol in combination with a drug like lorazepam to help get an agitated patient under better control," he said.

Dr. Breitbart said he has no relevant financial relationships with commercial interests.

[email protected]

LAS VEGAS – When it comes to treating depression in end-stage cancer patients, the side effects of psychotropics can prove almost as helpful as their primary indications.

"We tend to select drugs based on the side effects we want to utilize," said Dr. William S. Breitbart, chief of the Memorial Sloan-Kettering Cancer Center Psychiatry Service in New York.

For instance, sedating, constipating medicines such as tricyclics would be work well for a depressed patient with insomnia, diarrhea, and mouth sores. However, it would make sense to avoid those side effects in a patient with constipation or one who sleeps too much because of opioid pain management, he said.

Tricyclics also have some pain-fighting ability, and antidepressants in general help with dyspnea and can, along with neuroleptics, counter steroid side effects.

Drugs such as venlafaxine, mirtazapine, citalopram, and escitalopram are favored for terminally ill cancer patients, when possible, because they have little effect on the cytochrome P450 system, and so are unlikely to interfere with the blood levels of chemotherapeutic agents such as tamoxifen, Dr. Breitbart said at the Nevada Psychiatric Association’s Annual Psychopharmacology Update conference.

In addition, excitement in psychiatry about ketamine as an antidepressant has also been extended to patients in palliative care settings. However, Dr. Breitbart said, so far, there has not been enough controlled trials to support the use of ketamine with these terminal patients.

The side effects of other psychotropics are useful, too. Mirtazapine can help patients gain weight; olanzapine can do that, has analgesic properties, and helps with nausea and vomiting. Fitful sleep can be calmed by various agents with sedating properties.

Pain, metabolic abnormalities, anemia, adrenal insufficiency, hypogonadism, and chemotherapy agents themselves are among the factors that can contribute to depression in cancer patients. Patients with pancreatic cancer have higher rates of depression than do those with other intra-abdominal or retroperitoneal cancers, as well, perhaps because they have high levels of endogenous proinflammatory cytokines, which have been linked to depression.

About 60% of patients will respond to antidepressant therapy; individual and group psychotherapy, music and relaxation therapy, and social support help, too.

Psychostimulants help improve mood, cognition, and concentration, as well. "We occasionally use combinations of psychostimulants with [selective serotonin reuptake inhibitors] to jump-start the effect of the antidepressant agent." They also potentiate the analgesic effect of opioids and counteract their sedation, "so you can achieve analgesia at higher [opioid] doses" instead of limiting them because of sedation, Dr. Breitbart said.

Rather then suppressing appetite, psychostimulants give cancer patients a better sense of well-being and improve their appetite, which may help them gain a few pounds.

It’s a challenge to identify depression in advanced cancer, because fatigue, weight loss, and other effects of cancer and its treatment mimic depression. One solution is to increase the threshold for depression diagnoses, requiring a couple more associated symptoms instead of the usual four. Also, just the simple question, "Have you been depressed most of the time for the past 2 weeks" is a great screening tool for advanced cancer patients, he said.

Dr. Breitbart said he has no relevant commercial interests.

[email protected]

LAS VEGAS – When it comes to treating depression in end-stage cancer patients, the side effects of psychotropics can prove almost as helpful as their primary indications.

"We tend to select drugs based on the side effects we want to utilize," said Dr. William S. Breitbart, chief of the Memorial Sloan-Kettering Cancer Center Psychiatry Service in New York.

For instance, sedating, constipating medicines such as tricyclics would be work well for a depressed patient with insomnia, diarrhea, and mouth sores. However, it would make sense to avoid those side effects in a patient with constipation or one who sleeps too much because of opioid pain management, he said.

Tricyclics also have some pain-fighting ability, and antidepressants in general help with dyspnea and can, along with neuroleptics, counter steroid side effects.

Drugs such as venlafaxine, mirtazapine, citalopram, and escitalopram are favored for terminally ill cancer patients, when possible, because they have little effect on the cytochrome P450 system, and so are unlikely to interfere with the blood levels of chemotherapeutic agents such as tamoxifen, Dr. Breitbart said at the Nevada Psychiatric Association’s Annual Psychopharmacology Update conference.

In addition, excitement in psychiatry about ketamine as an antidepressant has also been extended to patients in palliative care settings. However, Dr. Breitbart said, so far, there has not been enough controlled trials to support the use of ketamine with these terminal patients.

The side effects of other psychotropics are useful, too. Mirtazapine can help patients gain weight; olanzapine can do that, has analgesic properties, and helps with nausea and vomiting. Fitful sleep can be calmed by various agents with sedating properties.

Pain, metabolic abnormalities, anemia, adrenal insufficiency, hypogonadism, and chemotherapy agents themselves are among the factors that can contribute to depression in cancer patients. Patients with pancreatic cancer have higher rates of depression than do those with other intra-abdominal or retroperitoneal cancers, as well, perhaps because they have high levels of endogenous proinflammatory cytokines, which have been linked to depression.

About 60% of patients will respond to antidepressant therapy; individual and group psychotherapy, music and relaxation therapy, and social support help, too.

Psychostimulants help improve mood, cognition, and concentration, as well. "We occasionally use combinations of psychostimulants with [selective serotonin reuptake inhibitors] to jump-start the effect of the antidepressant agent." They also potentiate the analgesic effect of opioids and counteract their sedation, "so you can achieve analgesia at higher [opioid] doses" instead of limiting them because of sedation, Dr. Breitbart said.

Rather then suppressing appetite, psychostimulants give cancer patients a better sense of well-being and improve their appetite, which may help them gain a few pounds.

It’s a challenge to identify depression in advanced cancer, because fatigue, weight loss, and other effects of cancer and its treatment mimic depression. One solution is to increase the threshold for depression diagnoses, requiring a couple more associated symptoms instead of the usual four. Also, just the simple question, "Have you been depressed most of the time for the past 2 weeks" is a great screening tool for advanced cancer patients, he said.

Dr. Breitbart said he has no relevant commercial interests.

[email protected]

LAS VEGAS – When it comes to treating depression in end-stage cancer patients, the side effects of psychotropics can prove almost as helpful as their primary indications.

"We tend to select drugs based on the side effects we want to utilize," said Dr. William S. Breitbart, chief of the Memorial Sloan-Kettering Cancer Center Psychiatry Service in New York.

For instance, sedating, constipating medicines such as tricyclics would be work well for a depressed patient with insomnia, diarrhea, and mouth sores. However, it would make sense to avoid those side effects in a patient with constipation or one who sleeps too much because of opioid pain management, he said.

Tricyclics also have some pain-fighting ability, and antidepressants in general help with dyspnea and can, along with neuroleptics, counter steroid side effects.

Drugs such as venlafaxine, mirtazapine, citalopram, and escitalopram are favored for terminally ill cancer patients, when possible, because they have little effect on the cytochrome P450 system, and so are unlikely to interfere with the blood levels of chemotherapeutic agents such as tamoxifen, Dr. Breitbart said at the Nevada Psychiatric Association’s Annual Psychopharmacology Update conference.

In addition, excitement in psychiatry about ketamine as an antidepressant has also been extended to patients in palliative care settings. However, Dr. Breitbart said, so far, there has not been enough controlled trials to support the use of ketamine with these terminal patients.

The side effects of other psychotropics are useful, too. Mirtazapine can help patients gain weight; olanzapine can do that, has analgesic properties, and helps with nausea and vomiting. Fitful sleep can be calmed by various agents with sedating properties.

Pain, metabolic abnormalities, anemia, adrenal insufficiency, hypogonadism, and chemotherapy agents themselves are among the factors that can contribute to depression in cancer patients. Patients with pancreatic cancer have higher rates of depression than do those with other intra-abdominal or retroperitoneal cancers, as well, perhaps because they have high levels of endogenous proinflammatory cytokines, which have been linked to depression.

About 60% of patients will respond to antidepressant therapy; individual and group psychotherapy, music and relaxation therapy, and social support help, too.

Psychostimulants help improve mood, cognition, and concentration, as well. "We occasionally use combinations of psychostimulants with [selective serotonin reuptake inhibitors] to jump-start the effect of the antidepressant agent." They also potentiate the analgesic effect of opioids and counteract their sedation, "so you can achieve analgesia at higher [opioid] doses" instead of limiting them because of sedation, Dr. Breitbart said.

Rather then suppressing appetite, psychostimulants give cancer patients a better sense of well-being and improve their appetite, which may help them gain a few pounds.

It’s a challenge to identify depression in advanced cancer, because fatigue, weight loss, and other effects of cancer and its treatment mimic depression. One solution is to increase the threshold for depression diagnoses, requiring a couple more associated symptoms instead of the usual four. Also, just the simple question, "Have you been depressed most of the time for the past 2 weeks" is a great screening tool for advanced cancer patients, he said.

Dr. Breitbart said he has no relevant commercial interests.

[email protected]