PALLIATIVE CARE PATIENTS ARE AT RISK OF ANTIDEPRESSANT DISCONTINUATION SYNDROME
Dr Maxine Glanger (1) , Professor Gregory Peterson (1)
1) Private, Newstead, Australia
Since the introduction of antidepressant drugs, a cluster of symptoms related to their dose reduction or cessation has been widely described as “antidepressant discontinuation syndrome”(ADDS). Antidepressants are commonly used in palliative care patients both for management of psychiatric disorders and several non-psychiatric symptoms of life-limiting illness. Palliative care patients may cease oral intake either temporarily or permanently for reasons related to their disease or its treatment, as well as the cessation of oral intake, which usually occurs in the days before death.
Aim: To estimate antidepressant use in palliative care patients stratified by risk of antidepressant discontinuation syndrome.
Design: A retrospective review of paper and electronic health records.
Setting/participants: We examined a cohort of 222 adults who died over a 12-month period under the care of an the specialist palliative care service Northwest Tasmania.
Results: Almost 40% of patients were recorded as having been on antidepressants at some point during their care: 20% were taking moderate to high risk antidepressants at referral to the service, 18.5% in the last month of life and 11 % were either commenced on, or switched to, moderate to high risk antidepressants during care, including during the last month of life.
- Zaini S, Guan NC, Sulaiman AH, Zainal NZ, Huri HZ, Shamsudin SH. The use of antidepressants for physical and psychological symptoms in cancer. Curr Drug Targets. 2018;19(12):1431-55.
- Kramer JK, D.; Fink,M. Withdrawal Symptoms Following Discontinuation of Imipramine Therapy. Am J Psychiatry. 1961;118(6):549-50.
- Jenkins J, Glass S. Catastrophic complications related to psychopharmacologic drug withdrawal. Psychiatr Ann. 2016;46(8):466-72.
- Haddad P. The SSRI discontinuation syndrome. J Psychopharmacol. 1998;12(3):305-13.
(Further references are available on request)
TRIALS OF MEDICINAL CANNABIS IN PATIENTS WITH ADVANCED CANCER – OUR EXPERIENCE TO DATE
Prof Janet Hardy (1,2), Ms Georgina Huggett (1), Dr Ristan Greer (2), Dr Navid Amirabadi (1,4), Dr Alison Kearney (3), Prof Phillip Good (1,2,4)
1) Mater Health Services, Brisbane, Australia,
2) Mater Research - University of Queensland, Brisbane, Australia,
3) Royal Brisbane and Women’s Hospital, Brisbane, Australia,
4) St Vincent’s Private Hospital, Brisbane, Australia
Background: In February 2019, our group was awarded an Australian Medical Research Future Fund grant to undertake trials of medicinal cannabis in cancer patients receiving palliative care. Since that time we have launched 3 trials across 4 sites in Queensland:
1. an open label dose escalating pilot study of cannabidiol (CBD) 100mg/ml and tetrahydrocannabinol (THC) 10mg/ml (MCP)
2. a double blind randomised controlled trial (RCT) of dose-escalated CBD 100mg/ml vs placebo oil (MedCan-1)
3. a double blind RCT of dose-escalated THC/CBD 10mg/10mg/ml vs placebo oil (MedCan-2)
The primary outcome measure in all studies is the change in Edmonton Symptom Assessment Scale (ESAS) score. Response is defined as a ≥6-point reduction in ESAS score at day 14. Secondary outcomes included individual symptom scores to 28 days, opioid use, median dose at day 14, quality of life, anxiety/depression, global impression of change and toxicity including psychomimetic effects. All participants continue standard palliative care throughout the study and are reviewed weekly.
Methods: Data collected to date has been collected for feasibility analysis with a census point of end July 2020.
Results: The pilot study was completed in 4 months (1). MedCan-1&2 are continuing to recruit following a brief Covid-19 enforced shut down. At the current census point, a total of 120 participants have been recruited: 21 to the pilot, 75 to MedCan-1 (in 17 months) and 24 to MedCan-2 (11 months). The main reason for ineligibility has been recent cannabis use. The median age of participants is 66 (range 30-90years) and AKPS 70 (range 40-90%). The most common cancers to date are colorectal, gynaecological, lung and prostate and 56/99(57%, MC1&2 only) were on anticancer treatment at baseline. 53 %(64/120) of all participants have died (median survival from randomisation around 6 months (188 (range 7 to 654+ days). The study completion rate is 82% (98/120) at day 14 and 62% (74/120) at day 28. The most common reasons for attrition are deteriorating condition and belief that randomisation has been to placebo. A few participants have reduced their intake of “as required” analgesia but no participant has reduced their baseline opioid dose. The most common side-effect (all blinded data) has been drowsiness. 13 SAEs have been reported, none considered secondary to study drug/placebo. 31/120 (26%) participants have requested authorised medicinal cannabis scripts post-trial.
- Good P et al. An Open-Label Pilot Study Testing the Feasibility of Assessing Total Symptom Burden in Trials of Cannabinoid Medications in Palliative Care. J Palliat Care 2020;23(5):650-655
CLINICALLY SIGNIFICANT DEPRESSIVE SYMPTOMS ARE PREVALENT IN PEOPLE WITH EXTREMELY SHORT PROGNOSES BUT EVIDENCE FOR EFFECTIVE INTERVENTIONS ARE LACKING – SYSTEMATIC REVIEWS
Dr Wei Lee (1), Dr Marley Pulbrook (1), Dr Caitlin Sheehan (3), Dr Slavica Kochovska (2), Associate Professor Annmarie Hosie (4), Professor Elizabeth Lobb (4), Professor Deborah Parker (2), Professor Brian Draper (5), Dr Sungwon Chang (2), Professor Meera Agar (2), Professor David Currow (2)
1) St Vincent Hospital (Sydney), Darlinghurst, Australia,
2) University of Technology Sydney, Ultimo, Australia,
3) Calvary Hospital, Kogarah, Australia,
4) University of Notre Dame, Darlinghurst, Australia,
5) University of New South Wales, Randwick, Australia
Background: Depression is a debilitating condition often seen with advanced life-limiting illnesses. For individuals affected at the end-of-life, depression can amplify suffering, limit capacity for pleasure, meaning, and engagement with their loved ones. It may be associated with a desire for hastened death.
The recognition, assessment and management of clinically significant depressive symptoms in the setting of advanced life-limiting illnesses is complex and can be even more challenging in those with only days-to-weeks of life expectancy. This period is usually characterised by an increase in symptom burden and declining functional status. Frailty and associated symptoms (e.g. fatigue, delirium or dysphagia) may make it difficult for depressive symptoms to be recognised and assessed, and hinder affected individuals to engage with treatments, which might not work in time.
As this subset of the palliative population with extremely short prognoses and clinically significant depressive symptoms poses specific challenges, it is important to determine the prevalence and effective interventions for these symptoms. Currently, there is a lack of systematic review evidence to address this. The knowledge of this may quantify global burden, facilitate the recognition, assessment, and management, and inform future guideline and research.
Aim: To determine the prevalence of and effective interventions for clinically significant depressive symptoms in people with extremely short prognoses.
Methods: Systematic reviews (PROSPERO: CRD42019125119) of the electronic databases of MEDLINE, PsycINFO, Embase, CINAHL, and CareSearch for studies between 1994 to current (2019 for prevalence studies and 2020 for effective interventions) were performed.
7957 studies were identified through the electronic databases. 13 studies were included for data extraction. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n = 10 studies; extremely short prognoses: N = 905) using depression-specific screening tools was 50% (95%CI: 29%-70%; I2 = 97.6%). Prevalence of major and minor depression were 10% (95%CI: 4%-16%) and 5% (95%CI: 2%-8%), respectively. Major limitations included high heterogeneity, selection bias and small sample sizes in individual studies.
4903 studies were identified through the electronic databases. 224 studies were assessed for full-text eligibility. No eligible study was identified.
Conclusion: Clinically significant depressive symptoms were prevalent in people with extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms. Evidence supporting common interventions for these symptoms is lacking in this context, highlighting the need for high quality interventional research in this area.
AFTER DEATH CARE AT A CHILDREN'S HOSPICE: AN AUDIT AND CASE STUDY
Dr Christine Mott (1), Ms Kelly Oldham (1)
1) Hummingbird House Children's Hospice, Brisbane, Australia
Background: Research in paediatric palliative care continues to be an emerging area with a substantial growth in research around the clinical areas of end of life care, symptom management and parental bereavement (McNamara-Goodger & Feudtner, 2012). Research however is more limited during the time period after a child has died and up to the burial or cremation. Available research indicates that parents within a hospice setting had space, time and a gentle separation after their child had died, compared to a hospital setting (Davis, 2005; Forrester, 2008). Hummingbird House Children’s Hospice is Queensland’s only children’s hospice, offering palliative care and support for babies, children, young adults and their families. Care at the hospice can be from the point of diagnosis through to the end of the child’s life, including after death care and bereavement support.
Aim: To audit patient records for young people who were provided after death care at Hummingbird House, considering patient, family and admission demographics.
Results: After death care encompassed young people who are admitted for care at end of life and subsequently die, but also admissions after death who may or may not have been known to the service prior. Since opening in October 2016 to July 2020 49 young people have died at Hummingbird House, with a further 40 admitted after death for support. The demographics of these families and their hospice admissions are explored. A case study is also included to explore the experiences of one family’s journey and perspectives on this area of care.
Conclusion: Support in after death care a critical service provided by children’s hospices. Future approaches to increasing the available literature in this area is considered.
Davis, R. (2005). Mothers’ stories of loss: their need to be with their dying child and their child’s body after death. Journal of Child Health Care, 9 (4), 288-300. https://doi-org.ezp01.library.qut.edu.au/10.1177/1367493505056482.
Forester, L. (2008). Bereaved parents’ experiences of the use of ‘cold bedrooms’ following the death of a child. International Journal of Palliative Nursing,vol 14 (12).
McNamara-Goodger K., Feudtner, C. (2012) History and epidemiology. In: Oxford Textbook of Palliative Care for Children (eds A Goldman, R Hain, S Liben), 2nd edition, pp.3-12. Oxford University Press.
GOALS OF CARE DISCUSSIONS OVER THE COURSE OF A PATIENT’S END OF LIFE ADMISSION: A RETROSPECTIVE STUDY
Dr Natalie Perera (1), Ms Lisa O'Driscoll (1), Dr Michelle Gold (1), Dr Naomi Katz
1) Alfred Health, Prahran, Australia
Background: With advancements in medical technology, the dying experience is now frequently occurring in hospital (Australian Institute of Health and Wellbeing, 2016). This brings an increasing need for clear discussion and documentation regarding a patient’s resuscitation status and treatment limitations, now commonly referred to as a patient’s “Goals of Care (GOC)”. GOC discussions are associated with positive outcomes for patients and their families (Hanning et al. 2019, Bernacki, Block 2014, Weiner, Roth 2006). Regular discussion regarding GOC is important as patient priorities and values regarding end of life may change over time, particularly as deterioration occurs. However, medical practitioners often feel unprepared for these discussions (Schwartz et al. 2003, Gorman et al. 2005). At our institution, GOC discussions are conducted and documented by medical staff, with a recommendation that senior medical staff are involved. We wanted to understand how often these discussions occur, who they occur with, and how this changes as patients deteriorate and approach death.
Objectives: To review, in a cohort of patients who deteriorated and died in hospital, who was involved in discussions around GOC, and how this changed over the course of their admission.
Methods: Retrospective observational study of 80 consecutive deaths at Alfred Health between March 11th 2019 and April 9th 2019. Variables were collected according to the End of Life Care audit tool designed by the Australian Commission of Safety and Quality in Health Care. Descriptive statistics were used to summarise and present data. Ethics approval was obtained from the local Ethics Committee (HREC number: 148/20).
Results: Eighty patients were included in the study, of which 75 (93.6%) had GOC recorded at any time during their admission. Mean age at death was 75.0 (33.0-98.8) years, and median admission duration was 7.7 (0.8-55.1) days. Initial GOC were revised in 68% of cases. Involvement of medical staff in initial GOC discussions versus final GOC discussions was home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were included in 34.7% versus 31.4%, and family in 53.3% versus 86.3% of cases. Both initial and final GOC were documented primarily by the home team junior doctor (66.7% and 74.5% respectively). Patient’s preferences for care were discussed and documented in 60% cases. Finally, documentation that the patient was dying occurred for 92.0% of patients; this was communicated to the family in 98.6% of cases, and to the patient in 19.5% of cases.
Conclusions: In our study, as patients deteriorated, family involvement in GOC discussions increased, but patient involvement did not. Junior doctors were primarily involved in GOC conversations, and whilst senior clinician involvement did increase as patients deteriorated, junior doctors still remained most heavily involved.
Practice implications: Given their involvement in GOC discussions, junior doctors should be provided with education and training to equip them with skills to provide effective and compassionate end of life care, and increase patient and family involvement in GOC discussions. At our institution, we are currently exploring junior doctors’ confidence and competence with GOC discussions in order to enhance existing training.