Palliative Care
Cohort Study: One in Four Patients Demonstrates Covert Cognition Despite Behavioral Unresponsiveness
3 Jan, 2025 | 08:30h | UTCBackground: Cognitive motor dissociation (CMD) refers to the presence of specific neuroimaging or electrophysiological responses to commands in patients otherwise incapable of voluntary behavioral output. Detecting CMD is clinically relevant because its underdiagnosis may lead to premature decisions regarding goals of care, life-sustaining treatment, and rehabilitation efforts. Although several single-center studies have suggested that CMD may exist in 10–20% of patients with disorders of consciousness, larger multinational data were lacking, particularly using both functional magnetic resonance imaging (fMRI) and electroencephalography (EEG).
Objective: To determine how often CMD occurs in a large, multinational cohort of adults with impaired consciousness and to evaluate the clinical variables potentially associated with this phenomenon.
Methods: This prospective cohort study included 353 adults with disorders of consciousness recruited from six international centers between 2006 and 2023. Enrolled participants had at least one behavioral assessment using the Coma Recovery Scale–Revised (CRS-R) and underwent task-based fMRI, EEG, or both. Sites utilized validated analytic pipelines and automated data processing to minimize false positives. Participants were divided into two groups: those without observable responses to verbal commands (coma, vegetative state, or minimally conscious state–minus) and those with observable responses (minimally conscious state–plus or emerged). CMD was defined as the absence of any observable behavioral response to commands, combined with a positive command-following signal on fMRI or EEG.
Results: Among 241 participants with no overt command-following, 25% showed CMD through either fMRI alone, EEG alone, or both. CMD was more common in younger patients, those assessed later after injury, and those with traumatic brain injury. Interestingly, in 112 participants who did exhibit command-following on bedside exams, only 38% demonstrated confirmatory responses on fMRI or EEG. These findings support the notion that the tasks used for neuroimaging and electrophysiological assessments may require more sustained cognitive engagement than typical bedside evaluations.
Conclusions: CMD was identified in about one in four patients who lacked behavioral command-following. Combining fMRI with EEG likely increases detection rates compared to either modality alone. The results highlight the need for increased awareness of covert cognitive activity in this population, given potential ramifications for prognosis, family counseling, and clinical care.
Implications for Practice: Clinicians should consider the possibility of CMD in patients who appear unresponsive at the bedside. When feasible, employing both fMRI and EEG might reveal hidden cognitive capacities that can guide patient-centered decisions, encourage targeted therapies, and allow healthcare teams to respect potential consciousness and autonomy. However, such technologies remain limited to specialized centers.
Study Strengths and Limitations: Strengths include a diverse sample from multiple international sites and the integration of two complementary neurodiagnostic techniques. Limitations involve heterogeneous recruitment practices, variations in local data acquisition methods, and potential selection biases toward patients who survived until advanced testing was available. Additionally, the absence of standardized paradigms across sites reduced consistency of results.
Future Research: Further large-scale investigations should standardize fMRI and EEG protocols and determine whether earlier and more consistent identification of CMD affects functional outcomes. Efforts to refine and validate automated analytic pipelines could facilitate widespread adoption of these techniques in routine clinical settings.
Reference: Bodien YG, Allanson J, Cardone P, et al. Cognitive Motor Dissociation in Disorders of Consciousness. New England Journal of Medicine. 2024;391:598-608. DOI: http://doi.org/10.1056/NEJMoa2400645
Psychedelic-Assisted Therapy May Reduce Anxiety and Depression in Patients with Life-Threatening Diseases
20 Oct, 2024 | 18:02h | UTCBackground: Anxiety, depression, and existential distress are prevalent among individuals facing life-threatening illnesses, significantly impacting their quality of life. Traditional treatments often have limited efficacy in this population. Psychedelic-assisted therapy, involving substances like psilocybin and LSD under professional supervision, has been proposed as a potential intervention. However, these substances are illegal in most countries and pose potential risks.
Objective: To assess the benefits and harms of psychedelic-assisted therapy compared to placebo or active comparators in treating anxiety, depression, and existential distress in people with life-threatening diseases.
Methods: This Cochrane systematic review included six randomized controlled trials conducted in the USA and Switzerland between 2011 and 2022. A total of 149 participants (140 analyzed), aged 36 to 64 years with life-threatening illnesses (e.g., cancer), were randomized to receive psychedelic-assisted therapy using classical psychedelics (psilocybin or LSD) or MDMA. Interventions included preparatory sessions, the psychedelic experience, and integration sessions. Comparators were active placebos (e.g., low-dose psychedelic or niacin) or placebo. Primary outcomes were anxiety, depression, and existential distress measured 1 to 12 weeks post-intervention.
Results: Psychedelic-assisted therapy with classical psychedelics may reduce anxiety and depression compared to active placebo:
- Anxiety: Mean difference (MD) of −8.41 points on the STAI-Trait scale (20–80 range; 95% CI, −12.92 to −3.89; 5 studies, 122 participants; low-certainty evidence).
- Depression: MD of −4.92 points on the Beck Depression Inventory (0–63 range; 95% CI, −8.97 to −0.87; 4 studies, 112 participants; low-certainty evidence).
The effect on existential distress was mixed and very uncertain. No treatment-related serious adverse events or grade 3/4 adverse events were reported. Common mild to moderate adverse events included elevated blood pressure, nausea, anxiety, and transient psychotic-like symptoms, which resolved shortly after the sessions.
Conclusions: Psychedelic-assisted therapy with classical psychedelics may reduce symptoms of anxiety and depression in patients with life-threatening diseases, but the evidence is of low certainty due to methodological limitations and small sample sizes. The effects of MDMA-assisted therapy are very uncertain.
Implications for Practice: While findings are promising, clinicians should exercise caution due to the low certainty of evidence and legal restrictions surrounding psychedelic substances.
Study Strengths and Limitations: Strengths include randomized designs and standardized therapeutic protocols involving preparation and integration sessions. Limitations are high risk of bias due to unblinding, small sample sizes, potential expectation bias, and cross-over designs with carry-over effects.
Future Research: Larger, well-designed RCTs with rigorous blinding are needed to confirm these findings. Future studies should explore long-term outcomes, diverse patient populations, and strategies to mitigate bias, such as using active placebos and measuring expectancy effects.
RCT: Telehealth-Delivered Early Palliative Care Equivalent to In-Person Care in Advanced Lung Cancer
26 Sep, 2024 | 15:06h | UTCBackground: Patients with advanced lung cancer often face a high symptom burden and decreased quality of life (QOL), but access to early palliative care, which can improve these outcomes, remains limited. While telehealth has become increasingly utilized due to the COVID-19 pandemic, it is unclear whether virtual palliative care is as effective as in-person care.
Objective: To compare the effect of early palliative care delivered via secure video vs in-person visits on the quality of life of patients with advanced non–small cell lung cancer (NSCLC).
Methods: This multisite, randomized comparative effectiveness trial enrolled 1250 adults with advanced NSCLC from 22 cancer centers in the US between June 2018 and May 2023. Participants were randomized to receive either early palliative care via video visits or in person every four weeks. The primary outcome was QOL measured by the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire at 24 weeks. Secondary outcomes included caregiver participation in palliative care visits and patient and caregiver satisfaction with care, mood symptoms, coping, and prognostic understanding.
Results: By week 24, patients in both groups reported equivalent QOL scores, with the video visit group scoring a mean of 99.7 compared to 97.7 in the in-person group (difference of 2.0 points, 90% CI, 0.1-3.9; P = .04 for equivalence). Both groups experienced similar improvements in QOL from baseline (mean increase of 8.4 points for video visits and 6.9 points for in-person care). Caregiver participation in palliative care visits was lower in the video visit group (36.6% vs 49.7%; P < .001). No significant differences were found between the groups in caregiver QOL, patient or caregiver satisfaction with care, mood symptoms, or coping strategies.
Conclusions: Early palliative care delivered via telehealth was equivalent to in-person visits in improving QOL for patients with advanced NSCLC. This underscores the potential of telehealth to increase access to essential palliative care services for this population without compromising care quality.
Implications for Practice: Telehealth can provide a feasible alternative to in-person palliative care, especially for patients with advanced lung cancer who face barriers to in-person visits, such as transportation challenges. However, strategies to enhance caregiver involvement in virtual visits may need to be developed.
Study Strengths and Limitations: Strengths include the large, multisite randomized design and the use of validated outcome measures. Limitations involve the COVID-19 pandemic’s impact, which caused some intervention contamination due to unavoidable video visits in the in-person group. Additionally, caregiver participation was lower than expected, potentially limiting the generalizability of results regarding caregiver outcomes.
Future Research: Further studies should explore the long-term impact of telehealth on palliative care outcomes and investigate ways to enhance caregiver involvement in virtual care.
Perspective | Reconsidering the language of serious illness
26 Jul, 2023 | 13:29h | UTCReconsidering the Language of Serious Illness – JAMA (free for a limited period)
Commentary on Twitter
"When clinicians, from a position of authority, describe patients with respiratory failure as needing intubation, patients and families presume intubation is what should be done."
Reconsidering the Language of Serious Illness https://t.co/IXDtDDPYTw
— Shunichi Nakagawa (@snakagawa_md) July 24, 2023
Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach
26 Jul, 2023 | 13:20h | UTCGiving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach – Intensive Care Medicine (free for a limited period)
Commentary on Twitter
📢 Giving voice to critically ill patients! ⬇️ visual abstract including 15 concerns expressed by conscious patients at high risk of dying in #ICU to
➡️improve communication/support
➡️better meet needs
➡️support research on EoL & quality of dying/death
🖇️ https://t.co/pQK5B77eCW pic.twitter.com/BCRDkmD7SG— Intensive Care Medicine (@yourICM) July 24, 2023
ASCO Guideline | Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy
19 Jul, 2023 | 14:31h | UTC
Systematic Review | An evidence-base for the implementation of hospital-based palliative care programs in routine cancer practice
19 Jul, 2023 | 14:23h | UTC
Consensus Paper | Subcutaneous infusions of hydration and medication in adults
7 Jul, 2023 | 16:27h | UTC
SR | Medically assisted hydration in palliative care: uncertain effects on quality of life and survival
27 Jun, 2023 | 13:47h | UTCSummary: The Cochrane Review analyzed Randomized Controlled Trials (RCTs) to evaluate the impact of Medically Assisted Hydration (MAH) on the Quality of Life (QoL) and survival of adults receiving palliative care. A total of four studies involving 422 participants, all diagnosed with advanced cancer, were considered. Two studies compared MAH with placebo, and two compared it with standard care.
The primary outcome was QoL, assessed through validated scales, with survival and adverse events being secondary outcomes. Mean differences (MD) and risk ratios (RR) were calculated for continuous and dichotomous outcomes, respectively. However, results were inconclusive due to a very low certainty of evidence. Hence, it is unclear whether MAH improves QoL, prolongs survival, or leads to adverse events when compared to placebo or standard care.
The findings are only applicable to inpatients with advanced cancer at the end of life and do not transfer to other adults in palliative care with non-cancer, dementia, or neurodegenerative diseases, or those with an extended prognosis. The lack of high-quality evidence leaves clinicians to make decisions based on perceived benefits and harms for individual circumstances.
Article: Medically assisted hydration for adults receiving palliative care – Cochrane Library
Choosing Wisely | Recommendations for advance care planning
22 Jun, 2023 | 15:18h | UTCSee complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada
M-A | Advance care planning for frail elderly: are we missing a golden opportunity?
7 Jun, 2023 | 13:53h | UTC
RCT | Communication-priming intervention boosts goals-of-care discussions for seriously ill patients
29 May, 2023 | 11:12h | UTCIntervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness: A Randomized Clinical Trial – JAMA (free for a limited period)
Editorial: Conversations on Goals of Care With Hospitalized, Seriously Ill Patients – JAMA (free for a limited period)
See also: Visual Abstract
Commentary: Some Surrogate Endpoints Are Fine – By Dr John Mandrola
Pre-Post Study | Machine learning informs mortality risk, increases advanced care planning rates in hospitalized patients
28 Apr, 2023 | 12:54h | UTC
Commentary on Twitter
Communicating mortality predictions from #MachineLearning algorithm to hospitalists may help increase goals of care discussions with high-risk hospitalized patients. https://t.co/dyCmwybcJb @WashUi2db @HealthHandbook
— JAMA Network Open (@JAMANetworkOpen) April 19, 2023
Extracorporeal CPR dissemination and integration with organ preservation in the USA: ethical and logistical considerations
28 Apr, 2023 | 12:47h | UTC
Guideline | Significance of the comprehensive geriatric assessment in the administration of chemotherapy to older adults with cancer
28 Apr, 2023 | 12:43h | UTC
A systematic review on clinical guidelines of home health care in heart failure patients
28 Apr, 2023 | 12:41h | UTC
Opinion | Precision palliative care as a pragmatic solution for a care delivery problem
26 Apr, 2023 | 14:19h | UTC
Commentary from the author on Twitter (thread – click for more)
In the @JCO_ASCO‼️‼️, @ravi_b_parikh & I make the case for 🎯"Precision Palliative Care" 🎯as a pragmatic solution for a care delivery problem
A 🧵
Article https://t.co/1mYcaVIov4 pic.twitter.com/5Kj87rcuZK— Ramy Sedhom, MD, FASCO (@ramsedhom) April 22, 2023
ESMO Guideline | Prognostic evaluation in patients with advanced cancer in the last months of life
26 Apr, 2023 | 14:07h | UTC
SR | Association between advanced care planning and emergency department visits
18 Apr, 2023 | 13:21h | UTC
Palliative care in the intensive care unit: not just end-of-life care
31 Mar, 2023 | 13:21h | UTCPalliative Care in the Intensive Care Unit: Not Just End-of-life Care – Intensive Care Research
Advantages and challenges of using telehealth for home-based palliative care | Systematic mixed studies review
16 Mar, 2023 | 13:14h | UTC
The adult and pediatric palliative care: differences and shared issues
28 Feb, 2023 | 13:30h | UTC
Cohort Study | Aggressive end-of-life care is still common among older adults with metastatic cancer in the US
27 Feb, 2023 | 13:11h | UTCSummary: The study aimed to compare the markers of aggressive end-of-life (EOL) care between older adults with metastatic cancer who are nursing home (NH) residents and those who live in community settings. The study analyzed data from 146,329 patients who died from metastatic breast, colorectal, lung, pancreas, or prostate cancer between 2013 and 2017, and found that aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs. 58.3%). More than one hospital admission in the last 30 days of life and death in the hospital were the key markers associated with a higher prevalence of aggressive EOL care. The authors suggest that interventions targeting these factors could improve the quality of end-of-life care.
Prevalence of long-term decision regret and associated risk factors in a large cohort of ICU surrogate decision makers
22 Feb, 2023 | 12:22h | UTC
Commentary on Twitter
One in five #ICU surrogate decision makers experience moderate to strong regret about life support decisions in ICU.
Read the full article: https://t.co/epCXB4QHRY@jlvincen @ISICEM #FOAMed #FOAMcc pic.twitter.com/0Q3X2uFYk0
— Critical Care (@Crit_Care) February 20, 2023
Regulations on palliative sedation: an international survey across eight European countries
16 Feb, 2023 | 15:17h | UTC