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Biomedical subjects

Michael J Germain

Publications and source records attributed to Michael J Germain.

11 recordsLinked to original sources
PubMed2006

Renal palliative care.

Patients with chronic kidney disease have a shortened life expectancy and carry a high symptom burden. Clinicians need sophisticated expertise in pain and symptom management and skills in communication to meet the many needs of this population. This article reviews the literature and discusses prognosis, ethical and legal considerations, symptoms, treatment, and end-of-life issues. The field of nephrology is shifting from an exclusive focus on increasing survival to one that provides greater attention to quality of life. There is an opportunity to integrate many of the advances of palliative medicine into the comprehensive treatment of these patients.

Adult↗
PubMed2005

The family perspective of ESRD deaths.

BACKGROUND: Nephrologists need to become more aware of how patients die. METHODS: Families of patients who died after receiving dialysis at 5 New England nephrology clinics were contacted and informed about the study. Postal questionnaires were completed 6 to 10 weeks after deaths to elicit the family members' perspectives. The tool inquired about quality of dying, site of death, advance care preferences, whether dialysis was discontinued, and terminal symptoms. RESULTS: There were 188 deaths, and 86 completed questionnaires (46%) were returned. The majority (64%) of family members believed that the patient had a peaceful death, followed by those who were unsure (24%), and those who thought the death was not peaceful (12%). Most deaths took place in institutional settings (56% in the hospital and 14% in nursing homes), and one quarter (27%) of the deaths occurred at home. Whereas some respondents perceived that patients preferred treatment to primarily extend life (28%), more believed that relieving pain (49%) was of greater importance, and the balance (24%) were unsure. Three quarters of the patient population were observed to be in pain during their last week of life. Pain was assessed as being extremely or moderately severe in more than 90% of patients. The second most distressing symptom was weakness or fatigue, followed by dyspnea, gastrointestinal problems, anxiety, and depression. There was significantly less likelihood of pain in the last week of life for patients who died at home compared with those who died in an institution. CONCLUSION: Nephrologists need to explore new ways to improve symptomatic treatment and minimize suffering of dying dialysis patients. These findings are the first step in benchmarking the prevalence and severity of terminal symptoms.

Adult Children↗
PubMed2004

Acute renal failure and hyperkalaemia associated with cyclooxygenase-2 inhibitors.

BACKGROUND: The renal effects of cyclooxygenase-2 (COX-2) inhibitors have been incompletely elucidated, and acute renal failure (ARF) due to COX-2 inhibitors has been reported. METHODS: In order to determine the causes of ARF and hyperkalaemia in five patients during COX-2 inhibitor therapy, we carefully analysed case studies of consecutive in-patients or out-patients referred to our Renal Division over a 6-month period for ARF and hyperkalaemia who had recently received COX-2 inhibitors. RESULTS: ARF developed 2-3 weeks after COX-2 inhibitor therapy in five patients. The ARF was consistent with pre-renal azotaemia from renal hypoperfusion. Four patients were receiving the loop diuretic, furosemide. Four patients developed hyperkalaemia and decreased serum bicarbonate despite diuretic therapy, and one patient had changes in plasma renin activity and aldosterone levels consistent with reversible hyporeninaemic hypoaldosteronism. Renal failure was reversible after discontinuation of diuretics and COX-2 inhibitors. CONCLUSIONS: COX-2 inhibitors may cause reversible ARF and hyperkalaemia in patients with oedematous conditions treated with low sodium diets and loop diuretics.

Acute Kidney Injury↗
PubMed2004

Palliative care.

Explore the source record for details and available documents.

Advance Care Planning↗
PubMed2004

Doxercalciferol safely suppresses PTH levels in patients with secondary hyperparathyroidism associated with chronic kidney disease stages 3 and 4.

BACKGROUND: Calcitriol lowers parathyroid hormone (PTH) levels in patients with chronic kidney disease (CKD) stages 3 and 4, but its use is limited by a low therapeutic index and concerns regarding hypercalcemia and acceleration of kidney disease. We evaluated doxercalciferol (1alpha-hydroxyvitamin D2) as an alternative therapy in a randomized, double-blinded, placebo-controlled, multicenter trial. METHODS: Fifty-five adults with stage 3 or 4 CKD and an intact PTH (iPTH) level greater than 85 pg/mL (ng/L) completed 8 baseline weeks, followed by 24 weeks of oral therapy with doxercalciferol or placebo. Pretreatment demographics and biochemical features did not differ between groups. Dosages were increased gradually if iPTH level was not decreased by 30% or greater and serum calcium and phosphorus levels were stable. Regular monitoring included plasma iPTH, serum calcium and phosphorus, urinary calcium, bone-specific serum markers, and serum lalpha,25-dihydroxyvitamin D levels. Glomerular filtration rate (GFR) was measured before and after treatment. RESULTS: Mean plasma iPTH level decreased by 46% from baseline after 24 weeks of doxercalciferol treatment (P <0.001), but was unchanged with placebo. After 6 weeks, iPTH level reductions with doxercalciferol treatment exceeded those with placebo at all subsequent intervals (P <0.001). No clinically significant differences in mean serum calcium or phosphorus or urinary calcium levels or incidence of hypercalcemia, hyperphosphatemia, or hypercalciuria were noted between groups. Serum C- and N-telopeptide and bone-specific alkaline phosphatase levels decreased with doxercalciferol treatment relative to both baseline and placebo (P <0.01). Adverse-event rates and changes in GFR did not differ between groups. CONCLUSION: Doxercalciferol is safe and effective in controlling secondary hyperparathyroidism of patients with CKD stages 3 and 4.

Aged↗
PubMed2003

The Renal Palliative Care Initiative.

Despite ongoing technological advances, patients with end-stage renal disease (ESRD) have a mortality rate of approximately 23% per year, and comorbid cardiovascular, cerebrovascular, and peripheral vascular disorders often make life on dialysis an ordeal. This patient population needs an improved approach to symptom assessment and control, as well as advance care planning and high-quality palliative care. Families need support during the lifetime and after the death of their loved ones. To address these needs, the Renal Palliative Care Initiative (RPCI) was instituted at Baystate Medical Center, a large tertiary care hospital, and at eight dialysis clinics in the Connecticut River Valley. With the cooperation of a large nephrology practice, the Western New England Renal and Transplant Associates, a core group of physicians, nurses, and social workers were trained in palliative medicine, and charged with the goals of developing and implementing innovative interventions. The RPCI's programs include symptom management protocols, advance care planning, and bereavement services for families and staff. The Initiative is increasing completion of formal advance directives by the patient population, while staff and families are particularly pleased with annual renal memorial services. The RPCI experience has much to offer the practice of nephrology, and it is relevant to ongoing efforts to extend palliative medicine beyond the traditional focus on cancer and AIDS.

Advance Directives↗
PubMedDate not supplied

Practical considerations in dialysis withdrawal: "to have that option is a blessing".

Cessation of life-support treatment is an appropriate option for situations in which the burdens of therapy substantially outweigh the benefits. Decisions to withdraw dialysis now precede 1 in 4 deaths of patients who have end-stage renal disease. Guidelines have been recently published to assist clinicians in making these complex and emotionally charged determinations, and they include: relying on shared decision making by all participants, obtaining informed consent, estimating the prognosis on dialysis, adopting a systematic approach for conflict resolution of disagreements, honoring advance directives, and ensuring the provision of palliative care. These principles are discussed in relation to an elderly man with dementia whose family decided to terminate maintenance hemodialysis.

Advance Directives↗
PubMedDate not supplied

Measuring quality of dying in end-stage renal disease.

Palliative medicine operates under the presumption that it is possible to improve the quality of a patient's death. Nephrology has justifiably taken pride in its reliance on internal benchmarking and the use of quality targets to shape clinical practice innovations, and this article discusses the efforts that are being made to measure end-of-life care of dialysis patients. A tool called the Dialysis Quality of Dying Apgar is described that examines five domains (pain, nonpain symptoms, advance care planning, peacefulness, and time) which are scored and then summed. A recent interdisciplinary workgroup of renal professionals has commissioned a series of focus groups that have attempted to ascertain patient and family values and preferences for the management of terminal situations. The results are summarized, and they should hopefully form a basis for the development of additional research and clinical measurement tools.

Advance Directives↗
PubMedDate not supplied

The psychiatric landscape of withdrawal.

Withdrawal from dialysis is an appropriate decision for situations in which the burdens of treatment outweigh the benefits. Alternately, it can be viewed as a public health problem and suicide equivalent that contributes to the high mortality of end-stage renal disease (ESRD). More than one in five deaths of patients with ESRD are preceded by dialysis cessation, and approximately 15,000 Americans died last year following a determination to stop this life-support treatment. This article discusses what is known about the psychosocial aspects of the patients who terminate dialysis, the role of depression and other psychiatric disorders, the family perspective, and the relationship of these decisions to suicide.

Attitude to Death↗
PubMedDate not supplied

Update on psychotropic medication use in renal disease.

Renal failure is a common medical condition, and many patients have comorbid psychiatric disorders. In this review, which is intended as a resource for consultation psychiatrists, the authors discuss pharmacokinetic considerations and provide information about the use of individual psychotropic medications in patients with renal disease. Most psychotropic medications are fat soluble, easily pass the blood-brain barrier, are not dialyzable, are metabolized primarily by the liver, and are excreted mainly in bile. Consequently, the majority of these drugs can be safely used with the end-stage renal disease population.

Anti-Anxiety Agents↗