PC-FACS
2015; Elsevier BV; Volume: 50; Issue: 3 Linguagem: Inglês
10.1016/j.jpainsymman.2015.07.001
ISSN1873-6513
Autores Tópico(s)Pharmacological Effects and Toxicity Studies
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] Kutner JS, Blatchford PJ, Taylor DH Jr, Ritchie CS, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691-700. Scheunemann LP, Cunningham TV, Arnold RM, Buddadhumaruk P, White DB. How clinicians discuss critically ill patients’ preferences and values with surrogates: an empirical analysis. Crit Care Med 2015;43:757-764. Mukae T, Uchida H, Ueda H. Donepezil reverses intermittent stress-induced generalized chronic pain syndrome in mice. J Pharmacol Exp Ther 2015;353:471-479. Weiner J, Sharma J, Lantos J, Kilbride H. Does diagnosis influence end-of-life decisions in the neonatal intensive care unit? J Perinatol 2015;35:151-154. Ray WA, Chung CP, Murray KT, et al. Out-of-hospital mortality among patients receiving methadone for noncancer pain. JAMA Intern Med 2015;175:420-427. Ferrante LE, Pisani MA, Murphy TE, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015;175:523-529. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med 2015;175:559-565. Risk-benefit profile of medications may change at the end of life. What is the safety and clinical impact of discontinuing statins in patients with limited life expectancy? This was a multicenter, parallel-group, noninferiority, unblinded clinical trial of the safety and clinical impact of discontinuing statin medications for patients with life-limiting illness. Eligibility included age ≥18 years, life expectancy ≥1 month, physician who would not be surprised by patient death in the next year, ≥3 months of statin therapy for primary or secondary prevention of cardiovascular disease (CVD), recent deterioration in functional status, and no recent active CVD. Patients were randomized to discontinue or continue statin therapy and followed for up to one year. Analyses followed an intent-to-treat approach. Primary outcome was percent mortality within 60 days; secondary outcomes included cardiovascular events, quality of life (QoL), symptoms, number of nonstatin medications, statin-related adverse effects, satisfaction with care, and cost. For patients with cognitive impairment, legally-authorized proxies reported only on objective patient-centered outcomes (PCOs). Discontinued patients (n = 189) were mean (SD) age 75 (12) years, 52% male, 81% white, 68% >5 years statin use. Continued patients (n = 192) were 74 (12) years old, 58% male, 84% white, 70% >5 years statin use. The 60-day mortality and time to first cardiovascular event were not statistically different between the two groups. Noninferiority was not achieved because the upper confidence limit for the difference in percent mortality at 60 days was 10.5%, higher than the prespecified noninferiority margin of 5%. Of PCOs, total QoL and psychological, well-being, and support subscales were better in the discontinued group. Mean daily cost-saving per patient was $3.37 (95% CI, 2.80-3.92) in the discontinued group. Given the multiplicity of symptoms typical in the advanced illness population, high caregiver burden, and rising costs of health care, the authors of this study pose important questions for our patients and their families, the hospice and palliative medicine community, and society at large. However, despite design changes midstream due to longer than anticipated patient survival, noninferiority was not achieved. Consequently, no conclusion can be made about the safety of discontinuing statins in this population with any statistical certainty. Notably, the study illustrates some of the myriad challenges of studying populations with life-limiting illness: prognostication, patient heterogeneity, PCO ascertainment for individuals with cognitive impairment, and selection of the appropriate population for the research question. Perhaps if the study had been restricted to patients with established CVD, the investigators would have obtained definitive results. The safety and clinical impact of discontinuing statins in patients with a limited life expectancy remains an unanswered question. Donna S. Zhukovsky, MD, FACP, FAAHPM, University of Texas M. D. Anderson Cancer Center, Houston, TX. Kutner JS, Blatchford PJ, Taylor DH Jr, Ritchie CS, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691-700. Shared decision making among clinicians and families, recommended for incapacitated patients, is based on understanding the patient’s preferences and values.1 How often do physicians and surrogates discuss these factors in goals-of-care discussions? This was a prospective, cross-sectional study of clinician–surrogate communication in intensive-care units (ICUs). Eligible participants were English-speaking families of incapacitated adult patients and their physicians. Patients were cared for in one of five ICUs in two California hospitals from 2006-2008. Clinician-surrogate conferences addressing life-sustaining treatment decisions were audio recorded, coded for mentions of the patient’s previously expressed preferences or values, and subcoded for eight domains of values commonly important to patients near the end of life. Patient participants (n = 71) were 58% male, mean (SD) 62 (17) years old, 48% white, mean (SD) number of ICU days 10 (10), and 37% neurologic failure on admission. Surrogates (n = 159) were 39% male, 37% white, 40% child of patient. Physicians (n = 54) were 59% male, 69% white, 74% internists. The patient’s previously expressed preferences or values were not discussed in 30% of conferences. Both preferences and values were discussed in 37%; and either preferences or values, but not both, were discussed in 33%. Physicians asked questions eliciting patients’ preferences and values in 48% of conferences with a mean of 1.7 (1.9) questions per conference. In 22% of conferences, clinicians made recommendations explicitly grounded in the patient’s preferences or values; in 88%, there was no discussion of the patient’s values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. Despite well-described methods of identifying incapacitated patients’ preferences,2 clinicians often fail to deliver end-of-life-care consistent with patients’ values.3 Worrisome data from this study indicate that the most frequent value discussed was longevity (32%), with body integrity and symptom palliation in a distant second place (each 17%); house staff led 33% of the discussions (half the time unaccompanied by the attending). When values and/or preferences were broached, surrogates raised the issues almost as frequently as clinicians (32% vs. 38%). The authors rightly note that further research should include correlation of such findings with clinical outcomes. (When longevity is highly valued, does aggressive care continue?) Nonetheless, if palliative care’s “procedure” is family meetings, we have a role to play assisting internists with determining patient’s goals and values during ICU care, be it through enhancing related competencies (education) or by collaborating in care. Clinicians generally fail to elicit both values and preferences of incapacitated, seriously ill patients. Hunter Groninger, MD, FAAHPM, MedStar Washington Hospital Center, Washington, DC. Scheunemann LP, Cunningham TV, Arnold RM, Buddadhumaruk P, White DB. How clinicians discuss critically ill patients’ preferences and values with surrogates: an empirical analysis. Crit Care Med 2015;43:757-764. 1.Thompson BT, Cox PN, Antonelli M, et al. American Thoracic Society; European Respiratory Society; European Society of Intensive Care Medicine; Society of Critical Care Medicine; Sociètède Rèanimation de Langue Française. Challenges in end-of-life care in the ICU: Statement of the 5th International Consensus Conference in Critical Care. Brussels, Belgium; April 2003: Executive summary. Crit Care Med 2004;32:1781-1784.2.Buchanan A, Brock D. Deciding for others: The ethics of surrogate decision making. Cambridge, UK: Cambridge University Press, 1989.3.Connors AF, Dawson NV, Desbiens NA, et al. A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274:1591-1598. Intermittent cold stress (ICS), a model for fibromyalgia-like pain, shows female-predominant sex differences and is sensitive to gabapentin and antidepressants.1,2 How does this model respond to the therapeutic actions of existing pharmaceuticals? Pain therapeutic actions of the pharmaceuticals pilocarpine and donepezil were assessed on an experimental fibromyalgia-like chronic pain model produced by ICS. Mice injected with intraperitoneal (IP), intracerebrovascular (ICV), or intrathecal (IT) pilocarpine or IP donepezil were tested for reversal of ICS-induced hyperalgesia through thermal and electrical paw withdrawal latency testing. Injections of the muscarinic antagonist pirenzepine, atropine, or morphine were co-administered using the same model. A single IP and ICV, but not IT, pilocarpine injection or 1-10 μg/kg IP or ICV donepezil administration attenuated ICS-induced thermal hyperalgesia and mechanical allodynia (P < 0.05); pirenzepine abolished responses. ICV pilocarpine rapidly reversed hyperalgesia, whereas IT pilocarpine had no effect. ICV atropine dose-dependently blocked the antihyperalgesia of IP donepezil. Repeated IP donepezil administration (10 μg/kg for 5 days) resolved ICS-induced hyperalgesia and allodynia; this effect was sustained even after cessation of drug treatment (P < 0.05). In control animals, short- and long-term administration of pilocarpine and donepezil did not alter nociceptive thresholds. ICV donepezil administration (10 μg/kg for 5 days) did not improve the poor analgesic response to ICV morphine reported with the ICS model,3 even after recovery of basal nociceptive thresholds in donepezil-treated mice, nor did it improve ICV morphine dose response analgesia in controls. Fibromyalgia remains a poorly understood intractable pain syndrome. Understanding the etiology and identifying treatment options require animal models that mimic its symptoms and pharmacotherapeutic sensitivities.1-3 Cholinomimetics act by directly stimulating the nicotinic or muscarinic receptors or indirectly by inhibiting cholinesterase, which promotes acetylcholine release. Mukae et al. utilized an established fibromyalgia mouse model1 to evaluate the therapeutic effects of two cholinomimetics, specifically pilocarpine and donepezil. Both improved pain control via supraspinal action, and repeated doses of donepezil had long-lasting analgesic effects. These data suggest the muscarinic cholinergic system inhibits some mechanisms underlying chronic pain in fibromyalgia, adding to a growing literature suggesting a role of cholinomimetics in neuropathic pain.4,5 Given the frequent use of donepezil in the treatment of dementia,6 this may be particularly relevant for the hospice and palliative medicine community. Preclinical data regarding the role of cholinomimetics for neuropathic pain is growing, but not ready for prime time. Eric Roeland, MD, FAAHPM, University of California San Diego Moores Cancer Center, La Jolla, CA. Mukae T, Uchida H, Ueda H. Donepezil reverses intermittent stress-induced generalized chronic pain syndrome in mice. J Pharmacol Exp Ther 2015;353:471-479. 1.Nishiyori M, Ueda H. Prolonged gabapentin analgesia in an experimental mouse model of fibromyalgia. Mol Pain 2008;4:52.2.Nishiyori M, Uchida H, Nagai J, et al. Permanent relief from intermittent cold stress-induced fibromyalgia-like abnormal pain by repeated intrathecal administration of antidepressants. Mol Pain 2011;7:69.3.Nishiyori M, Nagai J, Nakazawa T, Ueda H. Absence of morphine analgesia and its underlying descending serotonergic activation in an experimental mouse model of fibromyalgia. Neurosci Lett 2010;472:184-187.4.Boyle Y, Fernando D, Kurz H, et al. The effect of a combination of gabapentin and donepezil in an experimental pain model in healthy volunteers: results of a randomized controlled trial. Pain 2014; 155:2510-2516.5.Basnet A, Butler S, Honore PH, et al. Donepezil provides positive effects to patients treated with gabapentin for neuropathic pain: an exploratory study. Acta Anasthesiol Scand 2014;58:61-73.6.Birks J. Cholinesterase inhibitors for Alzheimer’s diseae. Cochrane Database Syst Rev 206;1:CD005593. Withholding life-sustaining treatment (LST) for critically ill neonates has become more common over the past decade, with a trend toward fewer infants receiving cardiopulmonary resuscitation (CPR).1 What is the effect of physiological status and diagnosis on end-of-life care for infants hospitalized in a neonatal intensive care unit (NICU)? This was a retrospective descriptive analysis of previously reported data for infants who died between 1999 and 2008 in a level IV NICU. Infants were categorized based on level of physiological status (stable or unstable) and diagnosis (very preterm [≤32 weeks gestation], congenital anomalies [regardless of gestational age], or other [including infants born at >32 weeks without congenital anomalies]). Primary outcome was level of care provided at end of life (care withheld, care withdrawn, or full resuscitation). Participants (N = 414) were mean (SD) gestational age 33 (6) weeks, mean (SD) birth weight 2055 (1182) grams, mean (SD) age at death 26 (44) days, 59% male. Mean (SD) maternal age was 27 (6.4) years. The most common causes of death were congenital anomalies (45%) and very preterm birth without congenital defects (35%). Very preterm newborns were more likely than infants with congenital abnormalities to receive CPR at time of death (26% vs. 13%; P < 0.01) and were more unstable (75% vs. 52%, P < 0.01). Infants age 22-24 weeks were significantly more likely to be unstable and to receive CPR at the time of death than other infants. Most infants who die do so in the ICU. Weiner et al.’s 2011 study showed that withholding of LST was an increasingly common cause of death in the NICU, concluding that this reflected growing recognition of medical futility. The current secondary analysis of those data reveals that, of all of the infants who died, those born at the threshold of viability (22-24 weeks) were most likely to be very unstable and to die in the midst of full CPR. Notably, median time to death for those infants was 4 days versus 21+ days for infants born at 25-32 weeks. This highlights several challenges for effective perinatal counseling. In the midst of families’ acute grief reactions and the compressed clinical time course, clinicians must join with families in choices to limit infant suffering. This may become increasingly relevant in light of recent media attention on resuscitation of infants who are even more premature.2 The most premature infants are at high risk of treatment decisions that may be consistent with medical futility; efforts to improve approaches to perinatal counseling and decision-making are needed. Renee D. Boss, MD, MHS, Johns Hopkins University School of Medicine, Baltimore, MD. Weiner J, Sharma J, Lantos J, Kilbride H. Does diagnosis influence end-of-life decisions in the neonatal intensive care unit? J Perinatol 2015;35:151-154. 1.Weiner J, Sharma J, Kilbride H, Lantos J. How infants die in the neonatal intensive care unit: trends from 1999 through 2008. Arch Pediatr Adolesc Med 2011;165:630-634.2.Rysavy MA, Li L, Bell EF, et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015;372:1801-1811. Methadone may extend the cardiac QT interval,1 potentially increasing the risk of death. How does methadone for noncancer pain affect the risk of out-of-hospital death? This was a retrospective cohort study of out-of-hospital mortality with sustained-release (SR) morphine and methadone using Tennessee Medicaid records from 1997 to 2009. The eligible cohort received morphine SR or methadone, did not have cancer, and were not residents of a care facility. Participants receiving methadone (n = 6014) were median (interquartile range [IQR]) 47 (41-54) years old, 58% female, 85% white, 88% opioid treatment for back or musculoskeletal pain, and median (IQR) opioid daily dose 40 (20-60) mg/d. The cohort receiving morphine SR (n = 32,742) were 48 (42-55) years old, 58% female, 84% white, 90% opioid treatment for back or musculoskeletal pain, median (IQR) morphine daily dose 90 (60-160) mg/d. Patients receiving methadone had a 46% increased risk of death during the follow-up period (adjusted hazard ratio [HR] 1.5, 95% CI, 1.2-1.8; P < 0.001), with an effective 72 (95% CI, 27-130) excess deaths per 10,000 person-years of follow-up. Methadone doses ≤ 20 mg/d were associated with increased risk of death (HR, 1.6; 95% CI, 1.0-2.5; P = 0.046) compared to a comparable dose of morphine SR (<60 mg/d). When pain became the fifth vital sign around 1995, a growing number of patients with chronic nonmalignant pain, especially back and musculoskeletal pain, were treated with opioids. At that time little was known about the risks of long-term opioid use, such as overdose, addiction, and morbidity. In 2009 methadone was linked to 30% of overdose deaths related to prescription painkillers despite the drug making up only 2% of prescribed painkillers.2 In this study, Ray and colleagues found that, for deaths from opioid overdose, methadone was associated with a two-fold increased risk. Despite the proarrhythmic effect of methadone, this study did not demonstrate an increased risk for sudden cardiac death but rather a 46% increased risk of death from overdose and respiratory/cardiovascular depression compared to morphine, which suggests the potency and prolonged half-life play a major factor in excess methadone-related deaths. Methadone should generally not be used for back or musculoskeletal pain. Dana Lustbader, MD, ProHEALTH Care Associates, Lake Success, NY and Hofstra North Shore-LIJ School of Medicine, Hempstead, NY. Ray WA, Chung CP, Murray KT, et al. Out-of-hospital mortality among patients receiving methadone for noncancer pain. JAMA Intern Med 2015;175:420-427. 1.Fredheim OM, Moksnes K, Borchgrevink PC, Kaasa S, Dale O. Clinical pharmacology of methadone for pain. Acta Anaesthesiol Scand 2008;52:879-889.2.Kuen BM. Methadone overdose deaths rise with increased prescribing for pain. JAMA 2012;308:749-750. Functional impairment is associated with acute care use and mortality in the elderly.1,2 Does existing functional status also predict hospital readmission rates and functional trajectories (FTs)? This was a prospective cohort study of FTs and mortality in community-dwelling individuals. Eligible participants were drawn from the longitudinal Precipitating Events Project, initially nondisabled in four basic activities, and admitted to an ICU. FTs were based on activity assessments. Participants (N = 291) were mean (SD) 84 (6) years old, 58% female, 89% white, 2 (1) chronic conditions, and 4 (4) disabilities. Pre-ICU trajectories were minimal (M, 30%), mild to moderate (MM, 44%), and severe disability (D, 27%). Twenty-four percent of individuals died in hospital or within 30 days of admission; FTs of the remaining participants (n = 221) were 21% M, 28% MM, and 51% D. Fifty-three percent experienced functional decline or death post-ICU. MM and D were associated with more than double (adjusted hazard ratio [AHR], 2.4; 95% CI, 1.3-4.5) and triple (AHR, 3.8; 95% CI, 1.8-8.0) risk of death within one year of ICU admission, respectively. One year mortality was 19% (M), 45% (MM), and 67% (D). This was a national cohort study of hospital readmission and functional impairment in community-dwelling persons. Primary outcome was 30-day readmission. Independent predictors were activities of daily living (ADL) and instrumental ADL (IADL) using a five-level integrated difficulty and dependent scale. A total of 7854 individuals had complete data; mean (SD) age 78.5 (7.7), 58.4% female, 86% ≥1 hospitalization within a year of index hospitalization. As functional impairment worsened, readmission rates increased: no functional impairment (13.5%); difficulty with ≥1 IADL (14%; odds ratio [OR], 1.1; 95% CI, 1.0-1.2); dependency in 1 or 2 ADL (17%; OR, 1.3; 95% CI, 1.1-1.4); and dependency in 3 or more ADL (18% OR, 1.4; 95% CI, 1.2-1.7). Patients experience an increased period of generalized risk after a hospital stay that has been coined the “post-hospitalization syndrome.”3 The studies by Ferrante et al. and Greysen et al. give evidence that prehospital functional status is an important factor in the poor health outcomes seen during and after an acute illness. Indeed, Ferrante et al. found that pre-ICU functional status carried with it a mortality risk similar to more traditional markers of disease severity (i.e., mechanical ventilation and shock). One implication of these findings is that interventions aimed at reducing the negative outcomes after an acute illness will likely miss the mark if they do not take into account factors contributing to a poor functional trajectory prior to admission. Wheels have been set in motion prior to hospitalization with regard to poor outcomes after an acute illness, highlighting the need for targeted interventions, including earlier palliative care, for those with severe premorbid disability. Eric Widera, MD, University of California San Francisco, San Francisco, CA. Ferrante LE, Pisani MA, Murphy TE, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015;175:523-529. Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med 2015;175:559-565. 1.Ferrucci L, Guralnik JM, Pahor M, Corti MC, Havlik RJ. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA 1997;277:728-734.2.Rozzini R, Sabatini T, Cassinadri A, et al. Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness. J Gerontol A Biol Sci Med Sci 2005;60:1180-1183.3.Krumholz, HM. Post-hospital syndrome - an acquired, transient condition of generalized risk. N Engl J Med 2013; 368:100-102. 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 Moses Sandrof and Jane Wheeler, MPH. AAHPM thanks the following PC-FACS Editorial Board members for their review of the critical summaries and preparatio of the commentaries: Basic Science Egidio Del Fabbro, MD, Senior Section Editor Fidel Davila, MD, MSMM 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 Ira Byock, MD, FAAHPM Valencia Clay, MD 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, AGSF, 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 Hospice, Hospice and Palliative Medicine Interface, and Regulatory Issues Tommie W. Farrell, MD, Senior Section Editor Janet H. Bull, MD, FAAHPM Charles S. Mills, MD, FACP J. Cameron Muir, MD, FAAHPM Joel S. Policzer, MD, FACP, FAAHPM Pediatrics Christina Ullrich, MD, MPH, Senior Section Editor Rene D. Boss, MD, MHS Marcia Levetown, MD, FAAP, FAAHPM Robert C. Macauley, MD, 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 Stephen J. Bekanich, MD, Senior Section Editor Amy P. Abernethy, MD, 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 Aaron Olden, MD, MS Eric Roeland, MD Ad Hoc Reviewers Mary Braun, MD 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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