PC-FACS
2015; Elsevier BV; Volume: 51; Issue: 2 Linguagem: Inglês
10.1016/j.jpainsymman.2015.12.308
ISSN1873-6513
Autores Tópico(s)Childhood Cancer Survivors' Quality of Life
ResumoPC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] Ornstein KA, Aldridge MD, Garrido MM, et al. Association between hospice use and depressive symptoms in surviving spouses. JAMA Intern Med 2015;175:1138-1146. Lichtenthal WG, Corner GW, Sweeney CR, et al. Mental health services for parents who lost a child to cancer: if we build them, will they come? J Clin Oncol 2015;33:2246-2253. Hill R, Lyndon A, Withey S, et al. Ethanol reversal of tolerance to the respiratory depressant effects of morphine. Neuropsychopharmacology 2015 Jul 14. [Epub ahead of print]. van Wijngaarden E, Leget C, Goossensen A. Ready to give up on life: the lived experience of elderly people who feel life is completed and no longer worth living. Soc Sci Med 2015;138:257-264. Narang AK, Wright AA, Nicholas LH. Trends in advance care planning in patients with cancer: results from a national longitudinal survey. JAMA Oncol 2015;175:1138-1146. Mao JJ, Bowman MA, Xie SX, et al. Electroacupuncture versus gabapentin for hot flashes among breast cancer survivors: a randomized placebo-controlled trial. J Clin Oncol 2015;33:3615-3620. Vase L, Vollertc J, Finnerup NB, et al. Predictors of the placebo analgesia response in randomized controlled trials of chronic pain: a meta-analysis of the individual data from nine industrially sponsored trials. Pain 2015;156:1795-1802. Hospice services include counseling to family members before and after a patient’s death.1-2 Does hospice care help ease depressive symptoms for surviving spouses after a typical grieving period?3 The Health and Retirement Study was used to identify patients who were married at the time of death and had died from ≥1 serious illness between August 2002 and May 2011. Their decedents were interviewed at 2-year intervals, prior to, and >1 year after the patient’s death. The primary outcome was change in depressive symptoms, measured by the Center for Epidemiologic Studies Depression (CES-D) Scale.4 Propensity matching compared a group that utilized hospice ≥3 days with a matching group that did not use hospice. Chi-square and unpaired two-tailed t- tests were used for bivariate comparisons. Regression analyses compared all spouses versus those who were primary caregivers. The final matched sample included 1016 decedent spouses (305 who had a hospice experience for ≥3 days in the year before death and 711 who did not). Regardless of hospice use or spousal caregiver status, 51.9% of spouses reported increased depressive symptoms before and after their loved one’s death. In the matched sample, 28.2% of spouses of hospice users had improved CES-D scores (mean change 1.9 points; SD 1.3) compared with 21.7% of spouses of decedents who did not use hospice (P=0.06). Multivariate analysis of propensity score-matched decedents indicated that hospice enrollment was associated with improved spousal depressive symptoms (OR, 1.64; 95% CI, 1.09-2.48). The association was most evident 1-2 years after the loved one’s death. In this study, depressive symptoms were remarkably common in bereaved spouses, with clinically significant depression increasing from the second assessment before death (23%) through the first assessment after death (42%), consistent with anticipatory then normal grief. Longer hospice stays were associated with greater reduction in depressive symptoms with a trend toward reduction in clinical depression. Of those who used hospice for ≥3 days, median length of stay on hospice was 22 days with mean 55 days, consistent with nationally reported data.5 This study offers further evidence that longer hospice stays benefit families after patients’ deaths and supports the value of hospice bereavement care. A hospice stay of ≥3 days was associated with fewer depressive symptoms in bereaved spouses 1-2 years after their loved one’s death. Christopher Jones, MD, FAAHPM, Main Line Health, Wynnewood, PA. Ornstein KA, Aldridge MD, Garrido MM, et al. Association between hospice use and depressive symptoms in surviving spouses. JAMA Intern Med 2015;175:1138-1146. 1.Park-Lee EY, Decker FD. Comparison of home health and hospice care agencies by organizational characteristics and services provided: United States, 2007. National Health Statistics Reports. DHHS Publication No. (PHS) 2011-1250. Issue No. 30; November 9, 2010.2.Department of Health and Human Services. Medicare Program; FY 2016 hospice wage index and payment rate update and hospice quality reporting requirements; final rule. FR 42 CFR Part 418; Doc. 2015-19033. August 6, 2015. Available at: http://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf. Accessed October 22, 2015.3.Caserta MS, Utz RL, Lund DA. Spousal bereavement following cancer death. Illn Crises Loss 2013;21:185-202.4.Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385-401.5.National Hospice and Palliative Care Organization. NHPCO’s facts and figures: Hospice care in America, 2015 ed. Alexandria, VA: National Hospice and Palliative Care Organization, 2015. Available at: http://www.nhpco.org/hospice-statistics-research-press-room/facts-hospice-and-palliative-care. Accessed December 1, 2015. Parents who have lost a child to cancer face intense, enduring grief.1-4 Are they receiving the mental health services (MHS) they need? This dual-center cross-sectional study assessed parents who lost a child to cancer 6 months to 6 years prior for MHS use and level of interest and perceived barriers to it. Of 204 households contacted, 120 parents (61% response rate) completed measures evaluating depression and anxiety, prolonged grief symptoms, attachment style, and meaning/purpose in life. Multivariable analysis examined associations between variables and MHS use. Most parents had used MHS (talk therapy, psychotropic medication, and/or support groups): 41% currently, 37% previously. Use was highest the first 2 years of bereavement. Forty-seven percent wished for “at least a moderate amount of assistance” (expressed need) and 23% had clinical levels of PG, depression, and/or anxiety (symptomatic need). Among those with expressed and symptomatic need, 40% and 38%, respectively, did not receive services. A minority were more likely to have unmet needs. Among those with either expressed or symptomatic need, the top two reasons for not receiving MHS were difficulty talking about the loss (64%) and difficulty finding help (60%). Therapy dropout rates were relatively high (40%). The most common reason for discontinuation was that it was not helpful. Multivariable analysis found depression symptoms, anxious and avoidant attachment styles, existential vacuum, and decreased meaning were associated with current MHS use. Parents bereaved by cancer, particularly those seeking ongoing connection with their oncology team, may find needed support in cancer center–based MHS. However, services vary and may not meet a given parent’s needs. Travel to the center may be prohibitive, especially if the parent is employed or cares for remaining children. For parents bereaved by non-cancer causes (the majority of bereaved parents), access barriers may be different. Efforts to understand the landscape of MHS for all bereaved parents are needed. This study highlights less visible but equally important access issues. Which MHS are most helpful and for which parents? How can pediatricians and hospice and palliative care clinicians better support bereaved parents in exploring which of the available MHS best fit their needs? MHS “meeting parents where they are” in conjunction with strategies addressing less visible access barriers may be the best approach to supporting bereaved parents. Christina Ullrich, MD, MPH, FAAHPM, Dana-Farber Cancer Institute, Boston, MA. Lichtenthal WG, Corner GW, Sweeney CR, et al. Mental health services for parents who lost a child to cancer: if we build them, will they come? J Clin Oncol 2015;33:2246-2253. 1.Kreicbergs UC, Lannen P, Onelov E, Wolfe J. Parental grief after losing a child to cancer: impact of professional and social support on long-term outcomes. J Clin Oncol 2007;25:3307-3312.2.van der Geest IM, Darlington AS, Streng IC, et al. Parents' experiences of pediatric palliative care and the impact on long-term parental grief. J Pain Symptom Manage 2014;47:1043-1053.3.Lichtenthal WG, Breitbart W. The central role of meaning in adjustment to the loss of a child to cancer: implications for the development of meaning-centered grief therapy. Curr Opin Support Palliat Care 2015;9:46-51.4.Lannen PK, Wolfe J, Prigerson HG, Onelov E, Kreicbergs UC. Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later. J Clin Oncol 2008;26:5870-5876. Chronic opioid and alcohol usage often co-occur.1-3 Does ethanol alter opioids’ analgesic and respiratory depression tolerance or increase the risk of overdose deaths?4-9 To determine the timing of analgesic and respiratory depression tolerance, mice were treated either with 75 mg continuous-release subcutaneously implanted pellets of morphine or twice-daily morphine injections (3-30 mg/kg) or methadone (60 mg/kg/day) or buprenorphine (5 mg/kg/day) by osmotic minipump implant. After 6 days, 0.3 g/kg ethanol was administered intraperitoneally, with or without concurrent injection of morphine (10 mg/kg). Changes in respiration (minute volume) before and after ethanol/morphine were observed while breathing 5% CO2 for 20 minutes, and analgesia (tail-flick latency) was assessed. Plasma and brain samples were analyzed for morphine, metabolites, and cortisol. ANOVA testing analyzed drug effects over time. Tolerance to analgesia and respiratory depression started after day 1 in the pellet-treated group; tolerance to analgesia was complete on day 2 and respiratory depression on day 5. The twice-daily morphine-injected mice exhibited analgesic tolerance but no tolerance to respiratory depression. Tolerance to respiratory depression in pellet-treated mice was not reversed with 0.3 g/kg ethanol alone but occurred with a concurrent ethanol and morphine challenge (10 mg/kg) on day 6. This was not seen in methadone- or buprenorphine-tolerant mice that received concurrent ethanol (0.3 g/kg) and morphine (10 mg/kg). Brain tissue assays showed that ethanol did not increase morphine levels in the central nervous system. Overdose is a common cause of death for heroin (diacetylmorphine) users. Death due to opioid overdose is thought to be a result of reduced tolerance after abstinence or combining heroin with other drugs, especially alcohol, which mutually reinforce one another, leading to respiratory depression and death. The authors of this study postulate an alternative hypothesis that ethanol reverses opioid tolerance to respiratory depression, leading to death. They show that bolus morphine and ethanol reverses established tolerance to respiratory depression. The clinical implications suggested are that patients on chronic opioids can experience respiratory depression when taking alcohol during dose escalation or opioid rescue dosing. This did not occur on chronic buprenorphine or methadone, implying different mechanisms to tolerance to respiratory depression. Using alcohol during opioid titration or rescue dosing with morphine may increase the risk of respiratory depression. Eric Prommer, MD, FAAHPM, Mayo Clinic Hospital, Phoenix, AZ. Hill R, Lyndon A, Withey S, et al. Ethanol reversal of tolerance to the respiratory depressant effects of morphine. Neuropsychopharmacology 2015 Jul 14. [Epub ahead of print]. 1.Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med 2013;125:115-130.2.Saunders K, Von Korff M, Campbell CI, et al. Concurrent use of alcohol and sedatives among persons prescribed chronic opioid therapy: prevalence and risk factors. J Pain 2012;13:266-275.3.Hedden SL, Martins SS, Malcolm RJ, et al. Patterns of illegal drug use among an adult alcohol dependent population: results from the National Survey on Drug Use and Health. Drug Alcohol Depend 2010;106:119-125.4.Shah NG, Lathrop SL, Reichard RR, Landen MG. Unintentional drug overdose death trends in New Mexico, USA, 1990-2005: combinations of heroin, cocaine, prescription opioids and alcohol. Addiction 2008;103:126-136.5.Rengade CE, Kahn JP, Schwan R. Misuse of alcohol among methadone patients. Am J Addict 2009;18:162-166.6.Nielsen MK, Johansen SS, Linnet K. Evaluation of poly-drug use in methadone-related fatalities using segmental hair analysis. Forensic Sci Int 2015;248:134-139.7.Llorente J, Withey S, Rivero G, et al. Ethanol reversal of cellular tolerance to morphine in rat locus coeruleus neurons. Mol Pharmacol 2013;84:252-260.8.Hull LC, Gabra BH, Bailey CP, Henderson G, Dewey WL. Reversal of morphine analgesic tolerance by ethanol in the mouse. J Pharmacol Exp Ther 2013;345:512-519.9.Dumas EO, Pollack GM. Opioid tolerance development: a pharmacokinetic/pharmacodynamic perspective. AAPS J 2008;10:537-551. Even when elderly people do not have a life-threatening illness, some feel disconnected from life, ready to die, and consider autoeuthanasia.1-2 What contributes to this lifeworld view?3 To understand why some people feel their life is “completed” and no longer worth living, 25 mentally competent people aged >70 years were interviewed in depth to explore their living experience. People were recruited and screened between April and September 2013; interviews were completed in December 2013. To determine whether severe depression contributed to their wish to die, participants were asked to complete the Hospital Anxiety and Depression Scale (HADS)4 immediately after their interview. Analysis of respondents’ answers was performed based on Dahlberg’s reflective lifeworld approach.3 Eleven males and 14 females, average age 83 years (range, 65-99), participated in the study. Interviews lasted 1.5-3.5 hours (median 1:56). Ten people had no serious illness. Most (21) had no anxiety; no one had more than mild anxiety. Fifteen had no indication of depression; three had moderate to severe depression. Five constituent themes of the phenomenon were repeated throughout the interviews: (1) loneliness (distance/detachment from others, lack of valuable relations); (2) the pain of not mattering (dispensable, unimportant to society, dwindling sense of belonging); (3) inability to express oneself (do activities central to one’s individuality, inability to care for others or share/gain new ideas); (4) multidimensional tiredness (physical deterioration, listlessness, sense of monotony or futility, fed up with life); (5) aversion to feared dependence (shame, fear, comparisons between actual versus desired life and resulting hopelessness). A growing Dutch minority support physician-assisted suicide/euthanasia for elderly people who are tired of living. Due to sample size and geographiclimitations, these results cannot be said to reflect a widely held attitude but can be reasonably extrapolated to a broader audience. The wish to die was determined to be influenced by sadness and loneliness, fears of losing independence/ autonomy, and unfulfilled needs to be valued and connected to others. This is a societal issue; marginalization and social exclusion demonstrates a need to question the role and place of elderly people in modern society. The authors stressed that wishing to die does not equal depression and noted the importance of distinguishing between a clinically defined disorder and existential suffering. Assistance to change social circumstances and relationships to palliate existential suffering and improve quality of life is a viable alternative for those requesting legal opportunities to end their lives. Valencia Clay, MD, FAAHPM, Walter Reed National Military Medical Center, Bethesda, MD. van Wijngaarden E, Leget C, Goossensen A. Ready to give up on life: the lived experience of elderly people who feel life is completed and no longer worth living. Soc Sci Med 2015;138:257-264. 1.Elder TE. The predictive validity of subjective mortality expectations: evidence from the Health and Retirement Study. Demography 2013;50:569-589.2.Chabot BE, Goedhart A. A survey of self-directed dying attended by proxies in the Dutch population. Soc Sci Med 2009;68:1745-1751.3.Dahlberg K, Drew N, Nyström M. Reflective lifeworld research. Lund, Germany: Studentlitteratur, 2008.4.Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-370. Advance care planning (ACP) is intended to help ensure that a person’s values and healthcare preferences are honored.1-4 How do cancer patients utilize ACP, and how does that affect5 end-of-life (EOL) choices? To study trends in various domains of ACP, this study utilized the Health and Retirement Study to identify patients who had died of cancer between 2000 and 2012. The authors interviewed 1985 next-of-kin surrogates who had complete information regarding activities of ACP, including living will status, durable power of attorney (DPOA) assignment, and participation in EOL discussions. In 79% of the cases, the decedents were the primary decision maker for EOL care. From 2000 to 2012, the percent of decedents with assigned DPOAs increased from 52% to 74% (P=0.03), but EOL discussions and the use of living wills did not change significantly (49% to 40%, P=0.63; and 68% to 60%, P=0.62, respectively). Rates of terminal hospitalizations remained unchanged (29% to 27%, P=0.70), but decedents’ reports of patients receiving “all possible care” at EOL increased from 7% to 58% (P=0.004). Being African American was associated with increased odds of receiving more aggressive treatment and dying in the hospital (AOR, 1.92; 95% CI, 1.03-3.42; and AOR, 3.69; 95% CI, 1.54-8.87, respectively). Factors that increased the odds of having treatments withheld at EOL were creation of a living will (AOR, 2.51; 95% CI, 1.53-4.11) and participation in EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14). DPOA assignment was not associated with limitation or withholding. This thoughtfully considered study demonstrates that even with significant increases in the assignment of proxy decision makers by patients, ACP patterns have changed little in 10 years. It also remains unclear whether these findings are concordant or at odds with patients’ preferences. Although early palliative care conversations limit aggressive EOL treatments6 and oncologists’ affect impacts outcomes,7 the study raises many new questions. For example, had DPOAs previously met the oncologist? Were these academic or private hospitals? Had a palliative care service been involved, and what effects might “goals of care” discussions have had on leading DPOAs to accept more or less aggressive EOL care? More research is needed to better understand the relationship between outcomes and the many variables that comprise ACP. Palliative care clinicians must help ensure that discussions occur between patients and their surrogates about the content of ACP so that wishes and care preferences are understood and surrogates are able and willing to carry them out. Jane E. Loitman, MD, MBA, FAAHPM, Washington University School of Medicine, St. Louis, MO. Narang AK, Wright AA, Nicholas LH. Trends in advance care planning in patients with cancer: results from a national longitudinal survey. JAMA Oncol 2015;175:1138-1146. 1.Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision aids for advance care planning: an overview of the state of the science. Ann Intern Med 2014;161:408-418.2.Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am 2015;99:391-403.3.Khandelwal N, Kross EK, Engelberg RA, et al. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med 2015;43:1102-1111.4.Schubart JR, Green MJ, Van Scoy LJ, et al. Advanced cancer and end-of-life preferences: curative intent surgery versus noncurative intent treatment. J Palliat Med 2015 Aug 11. [Epub ahead of print].5.Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014;28:1000-1025.6.Pirl WF, Lerner J, Eusebio J, et al. Association between oncologists' dispositional affect and depressive symptoms in their patients. Program and abstracts of the American Society of Clinical Oncology Annual Meeting; May 29-June 2, 2015; Chicago, IL. Abstract 9559.7.Fujisawa D, Temel JS, Traeger L, et al. Psychological factors at early stage of treatment as predictors of receiving chemotherapy at the end of life. Psychooncology 2015 May 8. [Epub ahead of print]. The placebo effect has been documented particularly during clinical trials of treatments that affect opioid receptors in the brain.1-4 What factors might contribute to this effect? This randomized double-blind trial followed 120 people to observe their response at 8 and 24 weeks to electroacupuncture, sham acupuncture, gabapentin, or placebo for the treatment of hot flashes in breast cancer survivors. The primary endpoint, was the change in hot flash composite score (HFCS; included frequency and severity) at 8 weeks. By week 8, sham acupuncture reduced the hot flash composite score more than placebo (-2.39; 95% CI, -4.60 to -0.17; P=0.035). Both electroacupuncture and sham acupuncture produced the most durable responses. Electroacupuncture had the greatest effect at 24 weeks (-8.1), followed by sham acupuncture (-6.1). The gabapentin and placebo groups experienced more adverse effects than the electroacupuncture or sham acupuncture groups. Approximately half of the participants correctly guessed that they had received the active treatment (electroacupuncture or gabapentin). This meta-analysis of 10 randomized double-blind placebo-controlled trials for chronic pain sought to determine whether baseline pain intensity and/or other factors influenced placebo responses. The primary endpoint was a placebo response as measured by differences in intensity of nociceptive pain from baseline through week 12. Dosing regimens were identical among all trials. Secondary analyses assessed the models’ predictive accuracy for placebo response. Opioid trials and the number of planned face-to-face visits during the trial period were positively associated with the magnitude of placebo response (22.5; 95% CI, 17.5-27.4; and 19.2; 95% CI, 17.6-21.3, respectively). In secondary analyses, models using baseline pain intensity, patient age, length of the washout period, and discontinuation due to adverse events were determined to account for about 10% of the variability in the placebo response. Mao and colleagues found the magnitude of placebo response in the pill group was similar to that observed in active interventional trials. Sham acupuncture elicited a greater placebo response than placebo pills. The placebo response is real; can be long-lasting; and emphasizes the importance of several aspects of care, including patient expectations, interactions with providers, and the potential impact of the treatment environment. Patients often expect a risk of harm related to medication management, observed by Mao and colleagues through a reasonably robust incidence of AEs related to placebo. Palliative care providers should carefully consider how the treatment environment, what we say, and how we say it can impact patients’ responses to our treatments. Vase and colleagues’ meta-analysis demonstrates that the type of active medication, number of face-to-face visits, and randomization ratio predicted the magnitude of the observed placebo response. Opioid trials, frequent visits, and lower ratios of active drug to placebo (1:1 vs 1:4) were associated with a more robust placebo response—additional evidence that patient expectations and the treatment environment can impact patient responses to the care we provide. Several factors can positively or negatively impact patients’ responses to medical interventions; understanding how gives hints to what might be done to optimize clinical outcomes. Michael A. Ashburn, MD, MBA, MPH, University of Pennsylvania, Philadelphia, PA. Mao JJ, Bowman MA, Xie SX, et al. Electroacupuncture versus gabapentin for hot flashes among breast cancer survivors: a randomized placebo-controlled trial. J Clin Oncol 2015;33:3615-3620. Vase L, Vollertc J, Finnerup NB, et al. Predictors of the placebo analgesia response in randomized controlled trials of chronic pain: a meta-analysis of the individual data from nine industrially sponsored trials. Pain 2015;156:1795-1802. 1.Price DD, Finniss DG, Benedetti F. A comprehensive review of the placebo effect: recent advances and current thought. Annu Rev Psychol 2008;59:565-590.2.Qiu YH, Wu XY, Xu H, Sackett D. Neuroimaging study of placebo analgesia in humans. Neurosci Bull 2009;25:277-282.3.Montgomery GH, Kirsch I. Classical conditioning and the placebo effect. Pain 1997;72:107-113.4.Bingel U, Wanigasekera V, Wiech K, et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med 2011;3:70ra14. PC-FACS Feedback We appreciate your feedback. Help us help you—send your comments to [email protected] PC-FACS was created in 2005 by Founding Editor-in-Chief Amy P. Abernethy, MD, PhD, FACP, FAAHPM. The Academy is deeply grateful to Dr. Abernethy for creating this important publication and for her many contributions to the field of hospice and palliative medicine. PC-FACS is edited by Editor-in-Chief, Donna S. Zhukovsky, MD, FACP, FAAHPM, of the University of Texas M. D. Anderson Cancer Center, and Associate Editor-in-Chief, Mellar P. Davis, MD, FCCP, FAAHPM, of the Taussig Cancer Institute at Cleveland Clinic. All critical summaries are written by Lana Christian. AAHPM thanks the following PC-FACS Editorial Board members for their review of the critical summaries and preparation of the commentaries: Basic Science Egidio Del Fabbro, MD, Senior Section Editor Rony Dev, DO, MS Khurram J. Khan, MD Eric Prommer, MD, FAAHPM Bioethics, Humanities, and Spirituality Francine Rainone, DO, PhD, MS, FAAHPM, Senior Section Editor Robert M. Arnold, MD, FAAHPM Valencia Clay, MD, FAAHPM Hunter Groninger, MD, FAAHPM Jessica A. Moore, DHCE, MA Alan J. Nixon, MB, BCh, BAO, CCFP(C), FAAHPM Gordon Wood, MD, MSci, FAAHPM Geriatrics and Care Transitions Paul Tatum, MD, MSPH, CMD, FAAHPM, Senior Section Editor David B. Brecher, MD, FAAFP, FAAHPM Laura C. Hanson, MD, MPH, FAAHPM Sandra Sanchez-Reilly, MD, MSc, AGSF, FAAHPM Eric Widera, MD, FAAHPM Hospice, Hospice and Palliative Medicine Interface, and Regulatory Issues Tommie W. Farrell, MD, Senior Section Editor Christopher Jones, MD, FAAHPM Matthew G. Kestenbaum, MD, FAAHPM Charles S. Mills, MD, HMDC, FACP, FAAHPM Joel S. Policzer, MD, FACP, FAAHPM Pediatrics Christina Ullrich, MD, MPH, FAAHPM, Senior Section Editor Rene D. Boss, MD, MHS Christopher A. Collura, MD, FAAP Marcia Levetown, MD, FAAP, FAAHPM Robert C. Macauley, MD, FAAP, FAAHPM Psychosocial Thomas B. Strouse, MD, Senior Section Editor Steven J. Baumrucker, MD, FAAFP, FAAHPM Myra Glajchen, DSW Stephanie M. Harman, MD, FACP Jane E. Loitman, MD, MBA, FAAHPM David Nowels, MD, MPH Symptom Assessment and Management Eric Roeland, MD, FAAHPM, Senior Section Editor Amy P. Abernethy, MD, PhD, FACP, FAAHPM Michael A. Ashburn, MD, MBA, MPH James T. D'Olimpio, MD, FACP, FAAHPM Daniel L. Handel, MD Dana Lustbader, MD, FCCM, FCCP, FAAHPM Ad Hoc Reviewers Jeanne-Marie Maher, MD, FACP Lisa E. Thompson, MD Denise G. Waugh, MD, FACEP, FAAHPM PC-FACS is partially supported through an unrestricted educational grant from Purdue Pharma, LP. The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 8735 W. Higgins Road, Suite 300 Chicago, IL 60631, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org
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