Prevalence and Natural History of Neuropsychiatric Syndromes in Veteran Hospice Patients

Context. Prospective studies are needed to adequately describe the overall impact of neuropsychiatric syndromes on the course of hospice enrollment in outpatient settings. Objectives. To determine the prevalence and natural history of delirium, cognitive impairment, alcohol abuse, anxiety, depression, and suicidal ideation (SI) in community-dwelling veteran hospice patients. Methods. Home hospice patients were visited regularly from enrollment until their deaths, study withdrawal, or discharge from hospice. Family caregivers gave consent for those with Mini-Mental State Examination (MMSE) scores less than or equal to 23. Measures included the Structured Clinical Interview for DSM-IV for depression (past and current) and alcohol abuse; the Hospital Anxiety and Depression Scale; MMSE; and Confusion Assessment Method (CAM). A clinicianrated CAM item documented sleep disturbance, and participants were asked about SI at each visit. Results. The median length of hospice enrollment was 81 days. Of 88 participants, 77 (88%) experienced at least one neuropsychiatric syndrome. Cognitive impairment was prevalent, with 60 (68%) registering MMSE less than or equal to 23 at least once. More than half of the participants developed delirium; the proportion with delirium, any cognitive impairment, sleep disturbance, or any neuropsychiatric syndrome increased significantly from first to last study visit. Twelve (14%) participants had SI during the study, and 30 (34%) participants were affected by depression overall. Sixteen patients who were not depressed on admission subsequently developed depression. Anxiety was present in 14 (16%) on at least one study visit. Active alcohol abuse remained relatively stable (8%) across visits. Conclusions. Psychiatric syndromes are highly prevalent in hospice patients. Systematic case finding of psychiatric disorders may be necessary to improv

Oregon Hospice Chaplains\u27 Experiences with Patients Requesting Physician-Assisted Suicide

Background: Oregon\u27s Death with Dignity Act (ODDA), which legalized physician-assisted suicide (PAS) for terminally ill individuals, was enacted in 1997. Eighty-six percent of the 171 patients who have died by PAS were enrolled in hospice. Objective: To survey hospice chaplains regarding their views on the ODDA and experiences working with patients who request PAS. Design: Single, anonymous, mailed survey. Subjects: All chaplains affiliated with one of Oregon\u27s 50 hospices. Results: Fifty of 77 hospice chaplains whom we identified (65%) returned the survey. Forty-two percent of respondents opposed the ODDA and 40% supported it. Over half of respondents had, in the previous 3 years, worked with a patient who had made an explicit request for assisted suicide. Conversation with patients around PAS focused on the role of faith and spirituality in this decision, reasons for wanting hastened death, and family concerns or reactions to PAS. Chaplains did not feel that they had a strong influence on the patient\u27s decisions about PAS (mean score of 4 on a 0–10 scale), though three chaplains reported a patient who withdrew their request for PAS because of the chaplain\u27s involvement. Chaplains reported provision of a nonjudgmental presence helped the relationship with the patient. Conclusion: Oregon hospice chaplains are divided in their views on legalized PAS, but primarily see their role to deliver support to patients no matter what the patient\u27s final decision regarding PAS