The American journal of hospice & palliative care

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SAGE Publications

Publications in this journal

• The Practical Nurse: A Case for COMFORT Curriculum Training.

  Authors: Elaine Wittenberg-Lyles, Joy Goldsmith, Brian Richardson, Jennifer S Hallett, Raymond Clark

  The American journal of hospice & palliative care.

  Licensed practical nurses provide the majority of bedside care in long-term care facilities and home care settings, and their communication with patients and families is pivotal to interventionsLicensed practical nurses provide the majority of bedside care in long-term care facilities and home care settings, and their communication with patients and families is pivotal to interventions aimed at reducing burdensome transitions to acute care settings. Although good communication skills are required for practical nurses, they receive limited instruction in their training. The goal of this study was to assess the effects of communication training for the practical nurse. A pre-post survey design was used to assess the COMFORT communication training curriculum provided to licensed practical nursing students. A comparison of mean scores on communication skills attitudes and perceived nursing competency revealed statistically significant improvement in attitudes and self-efficacy. This study shows promise for the feasibility and utilization of the COMFORT curriculum for nurse communication training. Further research should address the nurse's ability to perform COMFORT communication skills in the clinical setting.

• Factors and Structural Model Related to End-of-Life Nursing Care in General Ward in Japan.

  Authors: Saori Yoshioka, Michiko Moriyama

  The American journal of hospice & palliative care.

  This study aimed to determine the factors related to the implementation of end-of-life nursing care in general wards and to examine the adequacy of the hypothetical care implementation model. AThis study aimed to determine the factors related to the implementation of end-of-life nursing care in general wards and to examine the adequacy of the hypothetical care implementation model. A cross-sectional survey was conducted. As the results of multiple regression analysis, 8 factors were determined: subjective evaluation of nurses' own team, positive attitudes toward caring for dying persons, existence of a role model, death relief (Death Attitude Inventory), knowledge of symptom management knowledge of family assessment, abstract judgment skill, and participation in the seminar. The hypothetical model was constructed using these factors, and the adequacy of this model was confirmed by a structural equation modeling. These factors and the model would give suggestions of educational content and its method, which should be provided to general ward nurses.

• Effect of a Compassion-Focused Training Program in Palliative Care Education for Medical Students.

  Authors: Chih-Yuan Shih, Wen-Yu Hu, Long-Teng Lee, Chien-An Yao, Ching-Yu Chen, Tai-Yuan Chiu

  The American journal of hospice & palliative care.

  Background: Compassion is the key value of humanities perspective. Little is known, however, concerning the impact of enhancing compassion on ethical decision making in end-of-life care. METHODS: ABackground: Compassion is the key value of humanities perspective. Little is known, however, concerning the impact of enhancing compassion on ethical decision making in end-of-life care. METHODS: A total of 251 preclinical medical students were enrolled in a palliative care training course. A structured self-report questionnaire was administered before and after training. RESULTS: Experience with caring for patients with terminal cancer was positively related to improvement in the decision of "truth telling is helpful to a good death." In addition, improvement in the perception of "compassionate care" was correlated with higher improvement in the decision of "discharge planning and home care." Conclusion: Compassion-focused training program can be helpful to improve medical students' competence in making more appropriate ethical decisions in end-of-life care.

• Evaluation of End-of-Life Cancer Care in the ICU: Perceptions of the Bereaved Family in Japan.

  Authors: Satomi Kinoshita, Mitsunori Miyashita

  The American journal of hospice & palliative care.

  The purpose of this study was to investigate the evaluation of end-of-life care from bereaved family of cancer patients who had died in intensive care units in Japan. Cross-sectional anonymousThe purpose of this study was to investigate the evaluation of end-of-life care from bereaved family of cancer patients who had died in intensive care units in Japan. Cross-sectional anonymous questionnaire surveys were conducted on community dwelling individuals aged 40-79 who were randomly sampled from census tracts. End-of-life care was assessed using the Good Death Inventory and Care Evaluation Scale. The respondents were 4011 bereaved family and response rate was 40%. Of 390 respondents had experienced bereavement in intensive care unit. Of 152 respondents had lost a loved one due to cancer. The result showed that bereaved family of cancer patients evaluated lower than the non-cancer patients for "The doctors dealt promptly with discomforting symptoms of the patients' (p=0.009), 'The nurses had adequate knowledge and skills' (p=0.016), 'Admission (use) was possible when necessary without waiting' (p=0.008) , Consideration was given to the health of the family (P=0.039) and Physical and psychological comfort (p=0.03). Overall, it can be presumed that the cancer patients' bereaved family evaluated about symptoms management and doctors and nurses skills was low. There is a need to improve for end-of-life care of cancer patients and to conduct further research to explore quality-improvement interventions to bereaved family of cancer in intensive care unit.

• Current State of Pain Care for Hospitalized Patients at End of Life.

  Authors: Yingwei Yao, Gail Keenan, Fadi Al-Masalha, Karen Dunn Lopez, Ashfaq Khokar, Andrew Johnson, Rashid Ansari, Diana J Wilkie

  The American journal of hospice & palliative care.

  We report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical-surgical units located in 4 different MidwesternWe report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical-surgical units located in 4 different Midwestern hospitals over 24 months. We identified 1425 EOL care episodes, 596 (41.3%) of which had a pain diagnosis. The percentage of EOL patients with pain varied significantly across units (P < .001) and was even lower (27.7%) for those with "acute confusion." Additionally, 30% of EOL patients had severe or significant pain at death or discharge to hospice and only 42.7% actually met the expected pain-related outcome ratings. Pain often improved within 48 hours of admission (P < .005), the improvement, however, stagnated following this initial time period (P = .92). A sizable gap between pain science and clinical practice continues.

• Perceptions and Attitudes About Hospice and Palliative Care Among Community-Dwelling Older Adults.

  Authors: Erika Manu, Terri L Mack-Briggs, Caroline A Vitale, Andrej Galecki, Tisha Moore, Marcos Montagnini

  The American journal of hospice & palliative care.

  It is expected that the American geriatric population will have an increased need for hospice and palliative care services over the next few decades. We surveyed 187 community dwelling older adultsIt is expected that the American geriatric population will have an increased need for hospice and palliative care services over the next few decades. We surveyed 187 community dwelling older adults about several aspects related to end-of-life (EOL) care. Participants were much more familiar with the term hospice than palliative care. In general, they had positive attitudes towards hospice and palliative care. Although experience caring for a dying relative was common, it wasn't associated with better attitudes towards hospice and palliative care or better familiarity with these terms. Familiarity with the term palliative care was associated with better attitudes towards EOL care. Our findings highlight the need for enhanced end-of-life care education among older adults, and reinforce the need for further research in this area.

• Chronic Pain in the Outpatient Palliative Care Clinic.

  Authors: Jessica S Merlin, Julie Childers, Robert M Arnold

  The American journal of hospice & palliative care.

  Chronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. AsChronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. As palliative care continues to move upstream and outpatient palliative care programs develop, palliative care clinicians will be called upon to treat chronic pain. Chronic pain differs from acute pain in the setting of advanced disease and a short prognosis in terms of its etiology, comorbidities-especially psychiatric illness and substance abuse-and management. To successfully care for these patients, palliative care providers will need to learn new clinical competencies. This article will review chronic pain management core competencies for palliative care providers.

• Percutaneous Cholecystostomy in High-Risk Elderly Patients With Acute Cholecystitis: A Lifesaving Option.

  Authors: Murat Kapan, Akin Onder, Guven Tekbas, Mesut Gul, Ibrahim Aliosmanoglu, Zulfu Arikanoglu, Mustafa Aldemir

  The American journal of hospice & palliative care.

  Purpose: To analyze the results of percutaneous cholecystostomy in in high-risk elderly patients with acute cholecystitis. Materials and METHODS: Between June 2010 and May 2011, 11 patients aged overPurpose: To analyze the results of percutaneous cholecystostomy in in high-risk elderly patients with acute cholecystitis. Materials and METHODS: Between June 2010 and May 2011, 11 patients aged over 60 who had at least 1 systemic disease and underwent percutaneous cholecystostomy were reviewed retrospectively. RESULTS: The procedure was technically successful in 10 (90.9%) patients. Clinical improvement was achieved in 81.8% of patients within 72 hours. Two patients received emergency surgery while elective cholecystostomy was performed in 5 patients. Percutaneous cholecystostomy was performed singly in 4 (36.4%) patients. Early complication rate was 18.2%. Two (18.2%) patients died. Conclusion: Percutaneous cholecystostomy can be performed with low mortality and morbidity. Cholecystectomy should be performed in all patients with suitable general conditions due to the high recurrence rates of percutaneous cholecystostomy.

• On Sinking and Swimming: The Dialectic of Hope, Hopelessness, and Acceptance in Terminal Cancer.

  Authors: Emily Sachs, Elissa Kolva, Hayley Pessin, Barry Rosenfeld, William Breitbart

  The American journal of hospice & palliative care.

  For terminally ill cancer patients, hope and hopelessness are constructs that significantly impact quality of life. The aim of this study was to examine the relationship between hope and hopelessnessFor terminally ill cancer patients, hope and hopelessness are constructs that significantly impact quality of life. The aim of this study was to examine the relationship between hope and hopelessness in advanced cancer and to identify factors that maintain hope and increase vulnerability to hopelessness. Semistructured interviews were conducted with 22 terminally ill cancer patients. Interview transcripts were analyzed using thematic content analysis to identify patient definitions of these terms and associated cognitions and emotions. Hope and hopelessness were identified as distinct, often co-occurring, and dialectically interacting constructs. The relationship between hope and hopelessness often balanced on acceptance, perceived as diametrically opposed to hopelessness, and conducive to redirecting hope toward new goals. Positive interpersonal relationships enhanced hope, and uncontrolled physical pain increased vulnerability to hopelessness.

• Gabapentin for Pruritus in Palliative Care.

  Authors: Sheeba Anand

  The American journal of hospice & palliative care.

  Itch/pruritus can be very distressing in palliative care population and often is difficult to treat. Conventional antihistamines lack efficacy. Cutaneous and central pathogenesis of itch is extremelyItch/pruritus can be very distressing in palliative care population and often is difficult to treat. Conventional antihistamines lack efficacy. Cutaneous and central pathogenesis of itch is extremely complex and unclear, making its treatment challenging. Neuronal mechanisms have been identified in the pathophysiology of itch hence providing a myriad of therapeutic options. It has been established that pruritus and pain neuronal pathway interact with each other, hence neuropathic analgesics like gabapentin has shown to be efficacious antipruritic therapeutic option. Gabapentin impedes transmitting nociceptive sensations to brain, thus also suppressing pruritus. Gabapentin is safe and found to be effective in uremic pruritus, cancer/hematologic causes, opiod-induced itch, brachioradial pruritis, burns pruritus, and pruritus of unknown origin. Further research is required in this area to establish whether gabapentin is consistently effective.

• Mortality of Patients With Cancer Admitted to Intensive Care Unit.

  Authors: Silvio A Namendys-Silva, María O González-Herrera, Angel Herrera-Gómez

  The American journal of hospice & palliative care.

  Outcomes of critically ill cancer patients admitted to the intensive care unit (ICU) had improved; it could be associated with medical advances in critical care, introduction of new anticancerOutcomes of critically ill cancer patients admitted to the intensive care unit (ICU) had improved; it could be associated with medical advances in critical care, introduction of new anticancer treatments, and better supportive care. Recent reports have described ICU mortality for critically ill cancer patients ranged from 15.9% to 32%. During the period 2007 to 2011, a total of 1418 critically ill cancer patients were admitted to our ICU with a mortality rate lower (17.5%) than that reported by other centers. The ICUs around the world should consider the improvement in the prognosis of critically ill cancer patients who require critical care and they should not be denied ICU admission only on the basis of a patient having cancer.

• Impact of Patient and Caregiver Transfer Training Provided by a Physical Therapist in the Hospice Setting: A Case Study.

  Authors: Fernette Turner, Cindy Seiger, Nancy Devine

  The American journal of hospice & palliative care.

  Background: As patients in hospice become increasingly dependent upon caregivers, physical therapy interventions can minimize the risk of injury to the patient or caregiver that may occur duringBackground: As patients in hospice become increasingly dependent upon caregivers, physical therapy interventions can minimize the risk of injury to the patient or caregiver that may occur during transfers between surfaces. Case Description: A 68-year-old male hospice patient was referred to physical therapy for strengthening and transfer training after a fall that resulted in the patient remaining in bed for 5 weeks due to an increased fear of falling. Treatments focused on caregiver training for correct transfer techniques. Outcome: During 10 treatment sessions, the patient and caregiver became independent and safe with all transfers. Although the patient's health declined, his risk for and fear of falling decreased. Confidence with transfers improved for the patient and caregiver. Discussion: Physical therapy "benefits were immeasurable" for the patient and caregiver by teaching them how to safely perform patient transfers with reduced risk of injury.

• Why Do Cancer Patients Die in the Emergency Department? An Analysis of 283 Deaths in NC EDs.

  Authors: Ashley Leak, Deborah K Mayer, Annah Wyss, Debbie Travers, Anna Waller

  The American journal of hospice & palliative care.

  Emergency department (ED) visits are made by cancer patients for symptom management, treatment effects, oncologic emergencies, or end of life care. While most patients prefer to die at home, many dieEmergency department (ED) visits are made by cancer patients for symptom management, treatment effects, oncologic emergencies, or end of life care. While most patients prefer to die at home, many die in health care institutions. The purpose of this study is to describe visit characteristics of cancer patients who died in the ED and their most common chief complaints using 2008 ED visit data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). Of the 37,760 cancer-related ED visits, 283 resulted in death. For lung cancer patients, 104 died in the ED with 70.9% dying on their first ED visit. Research on factors precipitating ED visits by cancer patients is needed to address end of life care needs.

• Another conversation with stella.

  Authors: Dean George Gianakos

  The American journal of hospice & palliative care. 29(3):243.

• Comparison of Medical Expenditure According to Types of Hospice Care in Patients With Terminal Cancer.

  Authors: Taekyu Lim, Seung-Hyun Nam, Mi Sun Kim, Kyung Sook Yoon, Bong-Seog Kim

  The American journal of hospice & palliative care.

  Background: Hospice care is perceived as enhancing life quality for patients with advanced, incurable illness, but cost comparisons to nonhospice patients are difficult to make. Several studiesBackground: Hospice care is perceived as enhancing life quality for patients with advanced, incurable illness, but cost comparisons to nonhospice patients are difficult to make. Several studies demonstrated that palliative hospice care reduced medical expenditure in terminally ill patients compared with that of nonhospice care. METHODS: Patients with terminal cancer who were registered in Hospice Care Program (HCP) by the written consent and died during same admission period in Seoul Veterans Hospital, Seoul, Korea, between January 2009 and December 2009 were included. We compared medical expenditure according to the ward type (hospice ward and general ward) in patients who received palliative hospice care in Seoul Veterans Hospital, Korea. RESULTS: The daily total average expenditure for each inpatient was 193 930 and 266 161 in the hospice and general ward, respectively (P = .001). Daily expenditure of parenteral nutrition and laboratory blood tests/X-ray was also significantly lower in hospice ward compared with general ward (P = .002 and P = .006), respectively; 12 (17%) of 72 patients had been admitted in the intensive care unit during hospice care period in general ward (P = .014); 1 (3%) of 32 patients received blood products in hospice ward, but 13 (18%) patients received blood products in general ward during palliative hospice care (P = .039). Conclusion: Hospice ward type in palliative hospice therapy may contribute to reduce economic medical costs as well as to more specific total care for terminally ill patients with cancer.

• Hospice and Palliative Care Access Issues in Rural Areas.

  Authors: Susan Lynch

  The American journal of hospice & palliative care.

  All individuals deserve to have access to quality end-of-life care. In rural communities within the United States, significant barriers limit access to hospice and palliative care. They includeAll individuals deserve to have access to quality end-of-life care. In rural communities within the United States, significant barriers limit access to hospice and palliative care. They include issues related to geography and supply, health care system eligibility criteria, limitations of the available workforce, educational deficits, and differences in cultural values. This article examines the barriers and potential solutions to address the gaps in hospice and palliative care services in rural communities. Strategies are proposed to strengthen hospice and palliative care delivery models to enhance earlier referrals and provide better facilitation and transition to hospice and palliative care. Future research should look at patient utilization questions specific to rural communities.

• Parent's Perceptions of Health Care Providers Actions Around Child ICU Death: What Helped, What Did Not.

  Authors: Dorothy Brooten, Joanne M Youngblut, Lynn Seagrave, Carmen Caicedo, Dawn Hawthorne, Ivette Hidalgo, Rosa Roche

  The American journal of hospice & palliative care.

  Purpose: To describe parents' perspectives of health care provider actions that helped or did not around the time of infant/child's intensive care unit (ICU) death. Semistructured interviews with 63Purpose: To describe parents' perspectives of health care provider actions that helped or did not around the time of infant/child's intensive care unit (ICU) death. Semistructured interviews with 63 parents (Black, White, and Hispanic) 7 months post infant/child death were audio-recorded, transcribed, analyzed, and themes identified. Findings: What helped most: compassionate, sensitive staff; understandable explanations of infant's/child's condition; experienced, competent nurses; providers did everything to help infant/child; and parents' involvement in care decisions. What did not help: insensitive, nonsupportive staff; conflict between providers and parents; communication problems around the death; inexperienced nurses and doctors; parents not understanding child's disease, care, complications. CONCLUSIONS: Compassionate, sensitive staff and understandable explanations of children's conditions were most helpful; insensitive, nonsupportive staff least helpful by gender, racial group, or care setting. Conflict between providers and parents was most problematic for minority parents and mothers.

• Importance and Timing of End-of-Life Care Discussions Among Gynecologic Oncology Patients.

  Authors: Teresa P Díaz-Montes, Megan K Johnson, Robert L Giuntoli, Alaina J Brown

  The American journal of hospice & palliative care.

  Objectives: To assess the importance and desired timing of end-of-life care (EOLC) discussions among women with gynecologic cancer. METHODS: A questionnaire related to EOLC issues was distributed toObjectives: To assess the importance and desired timing of end-of-life care (EOLC) discussions among women with gynecologic cancer. METHODS: A questionnaire related to EOLC issues was distributed to patients with gynecologic cancer. Answers were analyzed via SPSS using descriptive statistics. Contingency analysis was done to evaluate for differences among disease status and age regarding preferences for timing of discussions. RESULTS: Patients expressed that addressing EOLC is an important part of their treatment. Most patients were familiar with advanced directives (73.0%), do not resuscitate/do not intubate (88.5%), and hospice (97.5%). Designating someone to make decisions was significantly related to disease status (P = .03) and age (P = 0.02). CONCLUSIONS: Patients are familiar with basic EOLC with optimal timing for discussions at disease progression or when treatment is no longer available.

• Trends in Services Among Pediatric Hospice Providers During 2002 to 2008.

  Authors: Lisa C Lindley

  The American journal of hospice & palliative care.

  The medical complexities involved in caring for children at end of life have increased during the past few decades. This study sought to understand what hospice services were offered for theseThe medical complexities involved in caring for children at end of life have increased during the past few decades. This study sought to understand what hospice services were offered for these children and to examine service trends among pediatric hospice providers over a 7-year (2002-2008) timeframe. The number of core hospice services diminished in 2003 (IRR = 0.873, 95% CI [0.795,0.971]) and 2004 (IRR = 0.889, 95% CI [0.793, 0.995]); however, by 2008 there was an increase in offering core (IRR = 1.130, 95% CI [1.038,1.230]), noncore (IRR = 1.117, 95% CI [1.013,1.231]), and other hospice (IRR = 1.117, 95% CI [1.005,1.583]) services among pediatric providers. These findings highlight the importance of family-clinician communication about needed services prior to admitting children to hospice care.

• Variation in the Incidence of Agitated Delirium During the Day in a Palliative Care Unit: A Preliminary Report.

  Authors: Ferraz Gonçalves, Ana Almeida, Luís Antunes, Sara Teixeira, Sara Pereira, Natércia Edra

  The American journal of hospice & palliative care.

  In the literature regarding delirium and agitation in palliative care, there are references of their worsening as the hours of the day flows from afternoon on, with an inversion of the awake-sleepIn the literature regarding delirium and agitation in palliative care, there are references of their worsening as the hours of the day flows from afternoon on, with an inversion of the awake-sleep cycle. We studied the frequency of the use of our protocol for the control of agitation. From June 18, 2007, to January 4, 2010, 27 (5.3%) patients from the 509 admitted were sedated intermittently 86 times, in strict compliance with the protocol, because of episodes of agitation. We verified that from 8 pm until 6 am, the number of observed cases clearly exceeds the expected cases, if the distribution was uniform. The reverse situation occurs in all other hours of the day. The chi-square goodness of fit test proves that the differences are statistically significant (P < .001).

• Looking Within and Reaching Out: Bereavement Counselor Perceptions of Grieving Adults With ID.

  Authors: Mary Ann Clute, Rie Kobayashi

  The American journal of hospice & palliative care.

  The purpose of this qualitative study was to explore the grief and loss experience of adults with ID through the eyes of 18 hospice-affiliated bereavement counselors. The data included interviewsThe purpose of this qualitative study was to explore the grief and loss experience of adults with ID through the eyes of 18 hospice-affiliated bereavement counselors. The data included interviews with hospice affiliated counselors who had provided grief counseling to adults with ID. The interview data were analyzed using grounded theory. The participants voiced clearly that loss needs to be recognized and grief must be honored for all persons, including those with ID. The participating counselors described the long histories of unrecognized losses and the unintended consequences of protecting people with ID by avoiding informing them or including them in change, loss, and death scenarios. The interview data depicted individuals with ID being so "invisible" that they are often disregarded in times of crisis and loss. The findings from this study, along with existing published literature, point out a serious need for education and training for families and formal and informal caregivers as well as professionals. Palliative care and hospice workers have an obligation and opportunity to identify, support, and, if necessary, treat the grief of those with ID. The hope is that over time, there will be less need for end-of-life care providers to be the lone educators and supporters about death and grief for any individual.

• Management of Severe Neuropathic Cancer Pain: An Illustrative Case and Review.

  Authors: Irene Connolly, Carolyn Zaleon, Marcos Montagnini

  The American journal of hospice & palliative care.

  Neuropathic cancer pain is common, very disabling and difficult to treat. It can be related to tumor invasion of neural structures and neuronal damage by surgery, chemotherapy and radiation therapy.Neuropathic cancer pain is common, very disabling and difficult to treat. It can be related to tumor invasion of neural structures and neuronal damage by surgery, chemotherapy and radiation therapy. Adjuvant analgesics are often used with opioids to control neuropathic pain in cancer patients. Methadone, a synthetic opioid with multiple mechanisms of action, is gaining increasing importance as an effective agent in the treatment of cancer related neuropathic pain. This case illustrates the challenges of managing severe pain in a patient with head and neck cancer while undergoing anti-tumor treatment. A review of the adjuvant analgesics and opioids, particularly methadone, in the management of neuropathic pain is also included.

• The Unlikely Patient and the Most Likely Patient: A Personal Reflection on 2 Patients and the Lessons Learned Regarding Physician Communication in the Field of Palliative Medicine.

  Authors: Babak M Goldman

  The American journal of hospice & palliative care.

  Palliative care is somewhat of a new field in medicine. A field which requires within it an intricate understanding of disease and its prognostic indicators. A field which considers the patient as aPalliative care is somewhat of a new field in medicine. A field which requires within it an intricate understanding of disease and its prognostic indicators. A field which considers the patient as a whole with the goal of patient-directed care. And a field which necessitates as much medicine as it does art. However, Palliative Care is often consulted by intensivists and primary teams during the last moments of life. And although we can be helpful during this time, we can be of more assistance when incorporated earlier by providing not only end-of-life care, but enhanced pain and symptomatic management, elucidating goals of care, as well as affording patients and their families with emotional, spiritual, and psychosocial support. Our expertise can be useful in all patients, not just the dying.

• Successful Use of Flupirtine in Refractory Neuropathic Pain Due to Small Fiber Neuropathy.

  Authors: Seema Mishra, Prakash Choudhary, Saurabh Joshi, Sushma Bhatnagar

  The American journal of hospice & palliative care.

  Small fiber neuropathy typically involves the small diameter nerve fibers, is usually idiopathic, and presents with peripheral pain. It can be excruciatingly painful at times despite the best ofSmall fiber neuropathy typically involves the small diameter nerve fibers, is usually idiopathic, and presents with peripheral pain. It can be excruciatingly painful at times despite the best of treatments. We present the case of a 22-year-old postoperative case of right frontoparietal oligodendroglioma who received multiple drugs for his severe neuropathic pain without significant relief. However, the pain almost completely subsided once flupirtine was added and substituted for some of the currently recommended first-line drugs.

• Parental Perceptions of Care of Children at End of Life.

  Authors: Mary Jo Gilmer, Terrah L Foster, Cynthia J Bell, John Mulder, Brian S Carter

  The American journal of hospice & palliative care.

  Objective: Little is known regarding the perceptions of parents about end-of-life care for their children. This study describes parental perceptions of the care of hospitalized, terminally illObjective: Little is known regarding the perceptions of parents about end-of-life care for their children. This study describes parental perceptions of the care of hospitalized, terminally ill children in the areas of (1) clinical management, (2) interdisciplinary support, and (3) pain and symptom management. Methods: Through a mixed methods design, researchers interviewed a representative sampling of bereaved parents via telephone. Results: Data provided evidence of areas which lack satisfaction with elements of end-of-life care of hospitalized children. Conclusion: Parental satisfaction with their child's care during end of life indicates need for improvement in pain management, communication, and parental involvement in decision making. While education cannot guarantee desired changes in attitudes or behaviors, it may provide the essential foundation of knowledge, skills, and ethical understanding needed by professional providers.

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