Journal Article Annotations
2022, 2nd Quarter

Palliative Care

Annotations by Barbara Lubrano di Ciccone, MD and R Garrett Key, MD
July, 2022

Dexmedetomidine: a magic bullet on its way into palliative care-a narrative review and practice recommendations.
What is a Good Death? A Choice Experiment on Care Indicators for Patients at End of Life.

PUBLICATION #1 — Palliative Care

Dexmedetomidine: a magic bullet on its way into palliative care-a narrative review and practice recommendations.

Jan Gaertner, Tanja Fusi-Schmidhauser

Abstract: Ann Palliat Med. 2022 Apr;11(4):1491-1504. doi: 10.21037/apm-21-1989. Epub 2022 Apr 6.

Background and Objective:
Dexmedetomidine is a potent adrenergic alpha-2 receptor agonist. It was first approved for sedation for mechanically ventilated patients. Being a sedative medication that is not associated with respiratory depression and holding analgesic properties fosters the interest for this drug in the palliative care field. The primary objectives of this review were to identify the key indications for the real-world use of dexmedetomidine in palliative care and other disciplines.

Methods:
A narrative review after extensive PubMed search was performed from 1950 to present on October 21st 2021. The language of the publications was restricted to English, German, French and Italian.

Key Content and Findings:
(I) Current dexmedetomidine use. There is a growing body of evidence that dexmedetomidine may reduce the incidence and severity of delirium, reduce opioid-consumption and postoperative nausea in intensive care settings. It is also used to facilitate withdrawal from different substances (alcohol, opioids, heroin). Concerning safety aspects of the drug, some studies reported an increased rate of serious cardiovascular events in patients with pre-existing heart conditions due to bradycardia and arterial hypo- and hypertension. Since the drug has a main hepatic metabolism, dose reduction is mandatory in patients with hepatic impairment. (II) Dexmedetomidine and palliative care. There have been sporadic case reports about the successful use of dexmedetomidine in palliative care. Indications for symptom control included sedation for hyperactive delirium, cancer pain, opioid-induced-hyperalgesia, dystonia, cough, vomiting, shivering and dyspnea. It is mainly applied via the intravenous (i.v.), subcutaneous, but also nasal and, buccal routes. Admixture (“syringe-driver”) studies showed that dexmedetomidine is compatible with morphine, hydromorphone, hyoscine and haloperidol. In 2021, a first prospective cohort study became available. Here, the authors reported promising result for dexmedetomidine use in hyperactive terminal delirium for reducing delirium intensity and agitation. Especially the unique “conscious sedation” or “awake sedation” that allows patients to arouse easily under sedation and report comfort or distress was discussed by the authors.

Conclusions:
In this review, we present the main findings for dexmedetomidine from palliative care settings and other disciplines. The potential benefits and criticalities of the drug are discussed and practical recommendations for its use are provided.

Annotation

The finding:
The use of dexmedetomidine appears safe for analgesia control in combination with opioids for palliative care patients. Dexmedetomidine provides “arousable sedation” without confusion allowing medical staff and family to communicate with patients. In addition, other promising properties of dexmedetomidine have been found in the amelioration of delirium, dyspnea, vomiting, shivering, sleep disorder, dystonia, and cough.

Strength and weaknesses:
This article also provides a thorough review of the pharmacological property of dexmedetomidine as well as its effect on several system organs. The authors primarily had to rely on case reports and one uncontrolled cohort study. Evidence came from different fields of medicine, and the authors did not include a systematic review methodology. Utilizing additional databases (e.g., Embase) may have revealed more relevant publications.

Relevance:
C-L psychiatrists often aid in the management of agitation and delirium in critical care settings. The use of dexmedetomidine could prove beneficial in the management of agitation and pain without overly compromising quality of life in terminally ill patients. In particular, patients remain arousable and communicative. The ability to be communicative is especially important in end-of-life care because it allows the patient to have important and meaningful interactions with their family and loved ones.

PUBLICATION #2 — Palliative Care

What is a Good Death? A Choice Experiment on Care Indicators for Patients at End of Life.

Juan Marcos Gonzalez Sepulveda, Drishti Baid, F Reed Johnson, Eric A Finkelstein

Abstract: J Pain Symptom Manage. 2022 Apr;63(4):457-467. doi: 10.1016/j.jpainsymman.2021.11.005. Epub 2021 Nov 15.

Context:
Health systems should aim to deliver on what matters most to patients. With respect to end of life (EOL) care, knowledge on patient preferences for care is currently lacking.

Objectives:
To quantify preference weights for key EOL care indicators.

Methods:
We developed a discrete choice experiment survey with 13 key indicators related to patients’ experience in the last six weeks of life. We fielded the survey to a web-panel of caregiver proxies for recently deceased care recipients. We obtained 250 responses in each of five countries: India, Singapore, Kenya, the UK and the US. Latent-class analysis was used to evaluate preference weights for each indicator within and across countries.

Results:
A 2-class latent-class model was the best fit. Class 1 (average class probability = 64.7%) preference weights were logically ordered and highly significant, while Class 2 estimates were generally disordered, suggesting poor data quality. Class 1 results indicated health care providers’ ability to control patients’ pain to desired levels was most important (11.5%, 95% CI: 10.3%-12.6%), followed by clean, safe, and comfortable facilities (10.0%, 95% CI: 9.0%-11.0%); and kind and sympathetic health care providers (9.8%, 95% CI: 8.8%-10.9%). Providers’ support for nonmedical concerns had the lowest preference weight (4.4%, 95% CI: 3.6%-5.3%). Differences in preference weights across countries were not statistically significant.

Conclusion:
Results reveal that not all aspects of EOL care are equally valued. Not accounting for these differences would lead to inappropriate conclusions on how best to improve EOL care.

Keywords:
End of life; discrete choice experiment; palliative; preference weights; relative importance; terminal illness.

Annotation

The finding:
Out of a list of common end-of-life (EOL) concerns, caregiver proxies ranked the ability to control their loved one’s pain as the most important. Clean, safe, and comfortable facilities along with the presence kind and sympathetic providers were the next most important aspects of EOL care. These concerns were considered more important than spiritual concerns, place of death, or access to high quality life-extending treatments.

Strength and weaknesses:
The samples were drawn from a variety of different countries, and the sample size was sufficiently large to produce a dataset to support high quality analysis. Limitations include that the report posed hypothetical rather than real-world choices and that the responses were from caregiver proxies rather than the actual patients.

Relevance:
Prioritization of pain management in EOL care is critical and may be the most important aspect of EOL care for most people.