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Biomedical subjects

R L Fainsinger

Publications and source records attributed to R L Fainsinger.

At least 19 recordsLinked to original sources
PubMed1998

Sedation for uncontrolled symptoms in a South African hospice.

The need to sedate terminally ill patients for uncontrolled symptoms has been previously documented in a few reports. A retrospective consecutive chart review was undertaken at a hospice in Cape Town, South Africa, to develop an understanding of the local experience and assess the potential for improved patient management. Twenty-three of seventy-six (30%) patients received sedating therapies: twenty patients for delirium, two patients for delirium and dyspnea, and one patient for dyspnea alone. Fourteen patients were sedated with a continuous subcutaneous infusion of midazolam, seven patients with intermittent doses of benzodiazepines, and two patients with chlorpromazine and lorazepam. The mean midazolam dose was 29 mg per day (median 30 mg; range 15-60 mg per day). Patients were sedated on average 2.5 days before death (median 1 day; range 4 hours-12 days). The mean equivalent daily dose of parenteral morphine in the last week of life showed a significantly higher mean for the sedated group, as compared to the nonsedated group. There was minimal investigation of reversible causes for delirium, none of the patients underwent an opioid rotation, and the opioid dose was seldom decreased. None of the patients received parenteral hydration. The prevalence for the use of sedating treatment is consistent with the range of other literature reports. Nevertheless, the wide disparity in the reported prevalence of these problems, and the ethical concerns raised by the relative frequency of this sedative approach, cannot be ignored.

Adult↗
PubMed1997

When to treat dehydration in a terminally ill patient?

The need to treat dehydration in terminally ill patients has become a very controversial topic. Numerous reports in the literature illustrate opposing view-points from both clinical and ethical perspectives. Arguments for the maintenance of hydration in terminally ill patients have tended to come from "the traditional medical model". Many health care professionals looking after terminally ill patients have reacted to the generalized use of intravenous fluids in dying patients and the perceived negative effects of this management. Our palliative care group has argued that the viewpoint that dehydration in dying patients is not a cause of symptom distress overlooks commonly reported problems, such as agitated delirium, that can be prevented or reversed by the management of dehydration. This review presents a summary of the traditional arguments, a different perspective on the controversy, biochemical parameters reported in terminally ill cancer patients, recent dehydration research, and the use of hypodermoclysis and rectal hydration. We conclude that the data reported to date are insufficient to allow a final conclusion on the benefit or harm of dehydration in terminally ill patients. Nevertheless, it is worth considering that while some dying patients may not suffer any ill effects from dehydration, there may be others who do manifest symptoms, such as confusion or opioid toxicity, that might be alleviated or prevented by parenteral hydration.

Dehydration↗
PubMed1997

Innovative palliative care in Edmonton.

PROBLEM BEING ADDRESSED: Access to palliative care in Edmonton has been hampered by uneven development, poor distribution of services, and more recently, economic restraints. Family physicians' involvement in palliative care has been hindered by the variety of access points, poor coordination, and inadequate reimbursement for time-consuming and difficult patient care situations. OBJECTIVE OF PROGRAM: To provide high-quality palliative care throughout Edmonton in all settings, with patients able to move easily throughout the components of the program; to lower costs by having fewer palliative care patients die in acute care facilities; and to ensure that family physicians receive support to care for most patients at home or in palliative care units. MAIN COMPONENTS OF PROGRAM: The program includes a regional office, home care, and consultant teams. A specialized 14-bed palliative care unit provides acute care. Family physicians are the primary caregivers in the 56 palliative continuing care unit beds. CONCLUSIONS: This program appears to meet most of the need for palliative care in Edmonton. Family physicians, with support from consulting teams, have a central role. Evaluation is ongoing; an important issue is how best to support patients dying at home.

Alberta↗
PubMed1996

Volume of hydration in terminal cancer patients.

In this retrospective study we reviewed the volume and modality of hydration of consecutive series of terminal cancer patients in two different settings. In a palliative care unit 203/290 admitted patients received subcutaneous hydration for 12 +/- 8 days at a daily volume of 1015 +/- 135 ml/day. At the cancer center, 30 consecutive similar patients received intravenous hydration for 11.5 +/- 5 days (P > 0.2) but at a daily volume of 2080 +/- 720 ml/day (P < 0.001). None of the palliative care unit patients required discontinuation of hydration because of complications. Hypodermoclysis was administered mainly as a continuous infusion, an overnight infusion, or in one to three 1-h boluses in 62 (31%), 98 (48%) and 43 (21%) patients, respectively. Our findings suggest that, in some settings, patients may be receiving excessive volumes of hydration by less comfortable routes such as the intravenous route. Increased education and research in this area are badly needed.

Administration, Cutaneous↗
PubMed1996

Integrating medical and surgical treatments in gastrointestinal, genitourinary, and biliary obstruction in patients with cancer.

Although local expertise needs to be considered, the following general guidelines for the palliation of malignant biliary obstruction have been proposed: (1) patients in good general condition with small tumors should undergo laparotomy to assess resectability and undergo surgical bypass; (2) patients with advanced disease and poor general condition are suitable for endoscopic stenting to reduce jaundice, pruritus, and risk of cholangitis; (3) patients with poor cognition and limited life expectancy should be managed pharmacologically as appropriate; and (4) research is required to assess optimal management for patients between these extremes; however, clinicians can use the previously described guidelines to make these difficult management decisions.

Cholestasis↗
PubMed1996

Rapid discontinuation of hypnotics in terminal cancer patients: a prospective study.

PURPOSE: To determine the proportion of patients receiving hypnotics upon admission to a palliative care unit, the frequency and intensity of withdrawal symptoms after rapid hypnotic discontinuation, and the effect of discontinuation on insomnia and cognitive failure. PATIENTS AND METHODS: 120 consecutive admitted patients. Rapid hypnotic discontinuation (1-4 days) was attempted. Insomnia (visual analogue 0 = best, 100 = worst for insomnia, restedness during the morning and difficulty falling asleep), cognition (Mini-Mental State Questionnaire), and withdrawal signs were monitored. RESULTS: Upon admission, 92/120 patients (77%) had been receiving hypnotics for a mean of 11 (standard deviation = 8) weeks. 4/92 patients (4%) refused hypnotic discontinuation. Acute mild withdrawal was observed in 2/88 patients (2%). The intensity of insomnia was not significantly different, while cognition significantly improved after hypnotic discontinuation. CONCLUSION: A large proportion of terminal cancer patients receives hypnotic drugs chronically. These drugs are probably not useful for the treatment of their insomnia, and rapid discontinuation can be safely achieved in most patients.

Adult↗
PubMed1996

Decreased opioid doses used on a palliative care unit.

We have previously published data on our use of opioids in the last week of life. A change in our pattern of opioid use, i.e. switching opioids more frequently and using high-dose methadone suppositories, appears to have resulted in a decrease in the number of patients requiring high-dose opioids. A retrospective chart review of 100 consecutive patients treated on our palliative care unit during 1992 was completed and compared to the original data from 1990. Results confirmed a decrease in the range of opioids used, as well as a statistically significant decrease in the daily opioid dose in the last week of life. We believe that this difference is most likely due to the use of methadone in patients showing either a poor response to other opioids or a rapid development to tolerance, as well as switching opioids more frequently to take advantage of incomplete cross-tolerance.

Aged↗
PubMed1995

Palliative care in Edmonton.

The Palliative Care Program at the Edmonton General Hospital, Edmonton, Canada provides a comprehensive multidisciplinary service to terminally ill patients in the area. The political, clinical, educational, and research developments impacting on this program are described.

Canada↗
PubMed1995

Reversible delirium in terminally ill patients.

Delirium is reported to be a common problem in terminally ill patients. The poor prognosis given to these patients may result in the failure to recognize the causes that are easily treated and may be reversible. We present four patients in whom a comprehensive assessment revealed a number of reversible causes of delirium, resulting in a treatment approach that significantly improved the patients' cognition and quality of life.

Aged↗
PubMed1995

Comparison of two different concentrations of hyaluronidase in patients receiving one-hour infusions of hypodermoclysis.

The purpose of this randomized, double-blind study was to compare 300 units of hyaluronidase per one-half liter to 150 units per one-half liter in patients receiving brief infusions for subcutaneous hydration. Twenty-five evaluable patients were randomized to receive a local injection of 300 units of hyaluronidase or 150 units of hyaluronidase immediately before two 1-hr infusions of two-thirds dextrose 5% and one-third normal saline solution (500 cc volume). The following day a crossover took place, and patients received the alternate treatment before each of the two 1-hr infusions. The intensity and swelling as reported by the patient (visual analogue scale 0-100), and the intensity of edema and rash as assessed by the investigator (score 0-4) were not significantly different between groups. The patients' and investigators' final choice was also not significantly different. Patients could not distinguish between bolus and their previous experience with overnight clysis. Our results suggest that brief infusions are well tolerated for subcutaneous hydration of patients with advanced cancer. A concentration of 150 units of hyaluronidase per one-half liter is well tolerated in this population.

Aged↗
PubMed1995

The frequency of alcoholism among patients with pain due to terminal cancer.

The purpose of this retrospective study was to determine the prevalence of alcoholism among terminally ill cancer patients when assessed by multidisciplinary interviews and by the CAGE Questionnaire. We reviewed the charts of 100 consecutive patients assessed by a multidisciplinary team for the presence of alcoholism during 1989, and 100 consecutive patients assessed by the CAGE Questionnaire during 1992. Alcoholism was diagnosed in 28/100 patients during 1989 (28%) and 18/66 patients during 1992 (27%). Thirty-four patients were unable to complete the CAGE Questionnaire in 1992 because of sedation or cognitive impairment; six of these patients (17%) were found to be alcoholics after multidisciplinary assessment. Only 9/28 (32%) and 8/24 (33%) patients diagnosed as alcoholics during 1989 and 1992, respectively, had been previously diagnosed as alcoholics according to the medical charts. The mean equivalent daily dose of morphine during admission and on Day 2 during 1992 were 153 +/- 193 mg and 183 +/- 198 for alcoholic patients, versus 58 +/- 80 and 70 +/- 79 mg for nonalcoholics (P = 0.06 and 0.03, respectively). The maximal dose of opioid and the pain intensity during admission, however, were not significantly different between alcoholics and nonalcoholics. Our results suggest that alcoholism is highly prevalent and underdiagnosed among symptomatic terminally ill cancer patients. The CAGE Questionnaire should be used for screening for alcoholism in this population. When multidimensional assessment and management of pain is applied, the outcome of alcoholic patients appears to be similar to that of nonalcoholics.

Aged↗