RESUMEN
PURPOSE: To describe educational features in palliative and end-of-life care (PEOLC) in pulmonary/critical care fellowships and identify the features associated with perceptions of trainee competence in PEOLC. METHODS: A survey of educational features in 102 training programs and the perceived skill and comfort level of trainees in 6 PEOLC domains: communication, symptom control, ethical/legal, community/institutional resources, specific syndromes, and ventilator withdrawal. We evaluated associations between perceived trainee competence/comfort in PEOLC and training program features, using regression analyses. RESULTS: Fifty-five percent of program directors (PDs) reported faculty with training in PEOLC; 30% had a written PEOLC curriculum. Neither feature was associated with trainee competence/comfort. Program directors and trainees rated bedside PEOLC teaching highly. Only 20% offered PEOLC rotations; most trainees judged these valuable. Most PDs and trainees reported that didactic teaching was insufficient in communication, although sufficient teaching of this was associated with perceived trainee competence in communication. Perceived trainee competence in managing institutional resources was rated poorly. Program directors reporting significant barriers to PEOLC education also judged trainees less competent in PEOLC. Time constraint was the greatest barrier. CONCLUSION: This survey of PEOLC education in US pulmonary/critical care fellowships identified associations between certain program features and perceived trainee skill in PEOLC. These results generate hypotheses for further study.
Asunto(s)
Cuidados Críticos , Educación de Postgrado en Medicina/métodos , Cuidados Paliativos , Cuidado Terminal , Adulto , Actitud del Personal de Salud , Competencia Clínica , Curriculum , Educación de Postgrado en Medicina/normas , Becas , Femenino , Humanos , Masculino , Análisis de Regresión , Estados UnidosRESUMEN
In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.
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Disnea/terapia , Cuidados Paliativos/métodos , Enfermedad Aguda , Disnea/diagnóstico , Humanos , Planificación de Atención al PacienteRESUMEN
BACKGROUND: In the United States, lung cancer is a major health problem that is associated with significant patient distress and often limited survival, with some exceptions. The purpose of this article is to address the role of palliative and end-of-life care in the management of patients with lung cancer and to address the need for good communication skills to provide support to patients and families. METHODS: This article is based on an extensive review of the medical literature up to April 2012, with some articles as recent as August 2012. The authors used the PubMed and Cochrane databases, as well as EBESCO Host search, for articles addressing palliative care, supportive care, lung neoplasm, and quality of life in cancer or neoplasm, with no limitation on dates. The research was limited to human studies and the English language. RESULTS: There was no "definitive" work in this area, most of it being concurrence based rather than evidence based. Several randomized controlled trials were identified, which are reviewed in the text. The article focuses on the assessment and treatment of suffering in patients with lung cancer, as well as the importance of communication in the care of these patients over the course of the disease. The aim of medical care for patients with terminal lung cancer is to decrease symptom burden, enhance the quality of remaining life, and increase survival benefit. A second objective is to emphasize the importance of good communication skills when addressing the needs of the patient and his or her family, starting at the time of diagnosis, which in itself is a life-changing event. Too often we do it poorly, but by using patient-centered communication skills, the outcome can be more satisfactory. Finally, the article addresses the importance of advance care planning for patients with lung cancer, from the time of diagnosis until the last phase of the illness, and it is designed to enhance the physician's role in facilitating this planning process. CONCLUSIONS: This article provides guidance on how to reduce patient distress and avoid nonbeneficial treatment in patients with lung cancer. The goal is to decrease symptom burden, enhance quality of life, and increase survival benefit. Good communication and advance care planning are vital to the process.
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Neoplasias Pulmonares/terapia , Cuidados Paliativos , Cuidado Terminal , Planificación Anticipada de Atención , Medicina Basada en la Evidencia , Humanos , Neoplasias Pulmonares/psicología , Estadificación de Neoplasias , Relaciones Médico-Paciente , Calidad de Vida , Estrés Psicológico , Suicidio AsistidoRESUMEN
INTRODUCTION: Patients with advanced lung or heart disease are not generally being treated consistently and effectively for relief of dyspnea. OBJECTIVES: The aim of the paper was to review available literature and to provide consensus statements using the Delphi method relevant to the topic condition. PATIENTS AND METHODS: A panel of experts of the American College of Chest Physicians (ACCP) defined the topic condition as "dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease." After a literature review, the panel developed 23 statements that were assessed for agreement/disagreement on a 5-point Likert scale using 2 rounds of the Delphi method. RESULTS: For the first round of the Delphi method, the survey was sent to the 15 expert panel members. Some statements were modified if deemed appropriate. For the second round of the Delphi method, 23 statements were sent to 56 clinicians from 5 relevant specialty NetWork steering committees of the ACCP. Agreement of at least 70% was achieved for 20 of the 23 statements. CONCLUSIONS: There was consensus that: patients with advanced lung or heart disease should be asked about the intensity and distress of their breathlessness; pursed-lips breathing, relaxation, oxygen for those with hypoxemia, noninvasive positive pressure ventilation, and oral/parental opioids can provide relief of dyspnea; therapies should be started with the understanding that the patient and clinician will reassess whether the specific treatments are relieving dyspnea without causing adverse effects; and it is important to communicate about palliative and end-of-life care.
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Consenso , Disnea/terapia , Cardiopatías/complicaciones , Enfermedades Pulmonares/complicaciones , Guías de Práctica Clínica como Asunto , Manejo de la Enfermedad , Disnea/etiología , Humanos , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea. METHODS: A panel of experts was convened. After a literature review, the panel developed 23 statements covering five domains that were considered relevant to the topic condition. Endorsement of these statements was assessed by levels of agreement or disagreement on a five-point Likert scale using two rounds of the Delphi method. RESULTS: The panel defined the topic condition as "dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease." The five domains were: measurement of patient-reported dyspnea, oxygen therapy, other therapies, opioid medications, and ethical issues. In the second round of the Delphi method, 34 of 56 individuals (61%) responded, and agreement of at least 70% was achieved for 20 of the 23 statements. CONCLUSIONS: For patients with advanced lung or heart disease, we suggest that: health-care professionals are ethically obligated to treat dyspnea, patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, both the patient and clinician should reassess whether specific treatments are serving the goal of palliating dyspnea without causing adverse effects, and it is important for clinicians to communicate about palliative and end-of-life care with their patients.
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Consenso , Manejo de la Enfermedad , Disnea/terapia , Cardiopatías/complicaciones , Enfermedades Pulmonares/complicaciones , Guías de Práctica Clínica como Asunto , Competencia Clínica , Disnea/etiología , Humanos , Estados UnidosRESUMEN
In obstructive lung disease, the characteristic change in spirometry is a reduction in the forced expiratory volume in the first second (FEV(1)) with respect to the vital capacity. Moreover, the severity of the obstruction can be graded by referencing spirometric measurements to age, sex, and height predicted normal values. Spirometry, however, should be considered a medical test, and not simply a vital sign that anyone can perform. Indeed, both technical issues and tester skills can profoundly affect the results and interpretations. Properly done spirometry can guide therapies and predict outcomes, but using spirometry to screen for obstructive lung disease in asymptomatic populations can be problematic, and the effects of screening spirometry on outcomes have yet to be determined. The value of spirometry is increased when it is of good quality, is interpreted properly, and is used in high-risk populations as a case-finding rather than a screening tool.
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Enfermedades Pulmonares Obstructivas/diagnóstico , Espirometría/normas , Volumen Espiratorio Forzado , Humanos , Enfermedades Pulmonares Obstructivas/fisiopatología , Tamizaje Masivo , Capacidad VitalRESUMEN
For many years the greatest barrier to the diagnosis and treatment of obstructive sleep apnea (OSA) was recognizing the disease. That obstacle is now fading as more physicians of all types are aware of the high prevalence of OSA and the consequences of untreated OSA. Sleep-laboratory polysomnography has long been considered the accepted standard for OSA diagnosis and has become a lucrative practice. This, unfortunately, has led to a concentration on diagnosis rather than on management of OSA. Although several brands of portable polysomnograph have been approved for home polysomnography, obstacles to reimbursement (primarily from government, but also from private payers) have prevented widespread home polysomnography. Over the last 2 decades many scientific studies have supported a strong correlation between the findings from home polysomnography and sleep-laboratory polysomnography. However, limited data are available from good outcomes-oriented studies, so controversy surrounds home polysomnography in the diagnosis of OSA. We review the evidence and debate whether sleep studies are appropriately done in the home.
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Monitoreo Ambulatorio/métodos , Polisomnografía/métodos , Apnea Obstructiva del Sueño/diagnóstico , Humanos , Factores de Riesgo , Apnea Obstructiva del Sueño/fisiopatologíaRESUMEN
UNLABELLED: GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications. METHODS: MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula. RESULTS: Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients. CONCLUSIONS: Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.
Asunto(s)
Neoplasias Pulmonares/terapia , Cuidados Paliativos/métodos , Medicina Basada en la Evidencia , Humanos , Neoplasias Pulmonares/complicacionesRESUMEN
Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.