Hospitalized patients at EOL had a much higher 24-hour IV morphine equivalents and CMI rates at time of death compared to CMI initiation. Variability was observed in the number of CMI rate adjustments and the number of bolus doses administered.
conditional on being alive and quality-adjusted life years are estimated and compared between the intervention and control arms.Results. ENABLE III is a recently completed fast-track trial at Dartmouth comparing palliative care intervention with the delayed start arm receiving palliative care after 3 months. Preliminary results show that the risk of death (hazard ratio [HR] (95% CI)) for immediate participants over the first year was 0.72 (95% CI, 0.57-0.89; p¼0.003). The difference of the primary patient-reported outcomes at 3 months was generally increased but not statistically different: for the FACITpal (immediate group estimated means [95% CI] 129.9 [126.6, 133.3] vs delayed group 127.2 [124.1, 130.3]; overall p¼0.34) and the QUAL-E symptom impact scale (11.4 [10.8, 12.1] vs 12.2 [11.6, 12.8]; overall p¼0.09).Conclusions. The joint modeling approach is an efficient and interpretable method for fast track palliative care study designs. ObjectivesDiscuss detailed findings regarding continuous morphine infusion prescribing patterns and limitations for end-of-life care patients at an academic US medical center. Promote discussion amongst the presenter and the audience members over issues surrounding opioid doses at the end of life and receive feedback/recommendations to optimize prospective validation of these findings. OriginalResearch Background. Continuous morphine infusions (CMIs) treat pain and dyspnea at the end of life (EoL). Ideally, opioid doses are tailored to individual opioid requirements and kidney function; however, CMIs are often rapidly escalated regardless of individual parameters. Rapid, unrestricted opioid escalation is not supported by opioid pharmacology. Research Objectives. The objective was to evaluate EoL CMI prescribing patterns. Methods. This retrospective chart review evaluated patients receiving CMI at EoL at a single academic US hospital (2013-2014). Statistical analyses of electronic medical record data was performed using SAS. Results. 161 patient charts were analyzed (68F, 93M, mean age 66.1AE16.2 yrs). At time of CMI initiation, 43.5% (n¼70) were opioid na€ ıve, and 24.8% (n¼40) had a GFR <30 mL/min. 64.6% (n¼104) did not receive any bolus doses prior to CMI initiation. The mean 24-hr IV morphine equivalent prior to CMI initiation was 44.8 mg (range: 0-1200 mg, SD 140.7) and 229.9 mg (21-5193 mg, SD 445.9) at time of death. The mean CMI starting IV rate was 3.4 mg/hr (0.4-30 mg/hr; SD 3.8) and 7.9 mg/hr (0.4-70 mg/hr; SD 9.9) at time of death. Mean number of CMI rate adjustments was 2.5 (0-25; SD 3.5) and number of bolus doses was 4.3 (0-27; SD 5.1). Mean time from CMI initiation to death was 15.2 hrs (0.05-126.9 hrs; SD 21.3). Patients received an increase of +413% 24-hr IV morphine equivalents or +132% CMI hourly rate. A positive association between time of death and total morphine received was observed (r¼0.16; p¼0.03).Conclusions. Hospitalized patients at EoL received variable and rapid escalations of hourly CMI rates within hours of death. A weak but statistically significa...
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