Palliative care in hospitals

Leadership's perceptions of palliative care during the COVID-19 pandemic: a qualitative study

CONTEXT

Palliative care played a leading role in the COVID-19 pandemic. However, little is known regarding health system leadership's perceptions.

BACKGROUND

This study aimed to explore the perceptions, understanding, and utilization of palliative care before compared to during the COVID-19 pandemic among health system leadership.

METHODS

Semi-structured, in-depth interviews were conducted with leaders in a large healthcare system based in Massachusetts, United States.

RESULTS

22 in-depth interviews were completed at four facilities. Emerging themes included the role of palliative care before compared to during the COVID-19 pandemic, facilitators and barriers to palliative care delivery, and recommendations for future practice. Participants reported that the COVID-19 pandemic increased palliative care utilization, reinforced positive perceptions of the specialty, and emphasized its role in maximizing healthcare efficiency. Many participants found palliative care financing to be a barrier to delivery; some had an inaccurate understanding of how palliative care is reimbursed. When asked about their recommendations for improving future practice, participants noted improvements in coordination within the healthcare system and education of healthcare providers and future physicians in primary palliative care skills.

CONCLUSIONS

Our findings suggest that health leadership increasingly understand the value of palliative care and its critical role within the health system and during future public health emergencies; this was further reinforced during the COVID-19 pandemic. Healthcare leadership recognize and highlight the need to increase investments in this specialty, both financially and educationally. In doing so, health care costs will be lowered, patient satisfaction will increase, and care will be better coordinated.

Prevalence and Predictors of Palliative Care Utilization among Hospitalized Patients with Diffuse Large B-Cell Lymphoma

Objective: Research has shown that palliative care improves the quality of life of cancer patients; however, there is no literature on specific factors that predict its use in diffuse large b-cell lymphoma (DLBCL) patients. Therefore, the prevalence of palliative care utilization and predictors of palliative care utilization among patients with DLBCL were examined. Methods: Data from the National Inpatient Sample (NIS) collected between 2016 to 2018 were used for all analyses. Multivariable logistic regression models were used to examine the predictors of palliative care utilization among hospitalized patients with DLBCL. Descriptive analyses were used to explore the overall prevalence of palliative care receipt in this population. Results: Of the 41,789 hospitalizations, 7.1% of patients used palliative care during hospitalization, while 4.8% utilized palliative care and were discharged alive. DLBCL patients aged 70 and older had 1.3 times (95% CI: 1.14-1.41) higher odds of utilizing palliative care compared to those less than 70 years. Relative to Medicare/Medicaid patients, those with other types of insurance were 1.7 times (95% CI: 1.34-2.05) more likely to receive palliative care. Those who were either transferred to a facility/discharged with home health (AOR: 6.23; 95% CI: 5.21-7.44) or died during hospitalization (AOR: 45.17; 95% CI: 36.98-55.17) had higher odds of receiving palliative care when relative to those with a routine hospital discharge. Other associated factors were type of admission, length of stay, chemotherapy receipt, and number of comorbidities. Conclusions: The prevalence of palliative care utilization was low and factors predicting utilization in our population were identified. Our findings highlight the need to increase awareness among medical oncologists on the need to involve the palliative care team early in the management of hospitalized patients with DLBCL.

Trends, Sociodemographic and Hospital-Level Factors Associated With Palliative Care Utilization Among Multiple Myeloma Patients Using the National Inpatient Sample (2016-2018)

BACKGROUND

Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on multiple myeloma (MM) specific factors. MM patients have a high symptom burden and early involvement of palliative could increase their quality of life. We examined factors associated with palliative care utilization among MM patients and explored prevalence trends in palliative care utilization among patients with MM.

METHODS

Cross-sectional analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore prevalence trends in palliative care utilization over time. Multivariable logistic regression models were used to examine sociodemographic and hospital-level factors associated with palliative care utilization in MM patients.

RESULTS

Overall prevalence of palliative care utilization in our population was 7.7% with a trend of increasing use of palliative care from 7.3% in 2016 to 8.2% in 2018. MM patients aged 70 years and above had 1.30 times higher odds (95% CI: 1.20-1.42) of receiving palliative care relative to those younger than 70 years. Compared to non-Hispanic whites, non-Hispanic blacks (Adjusted odds ratio (AOR): 0.86; 95% CI: 0.79-0.94) were less likely to utilize palliative care. Patients on Medicaid (AOR: 1.27; 95% CI: 1.08-1.49), private insurance (AOR: 1.27; 95% CI: 1.16-1.39) and other insurance types (AOR: 2.10; 95% CI: 1.79-2.47) had significantly higher odds of receiving palliative care when compared to those on Medicare. Other factors identified were hospital region, location, patient disposition, admission type, length of stay, and number of comorbidities.

CONCLUSION

Our findings highlight the urgent need for education of hospital physicians on the need for early palliative care involvement in the care of hospitalized MM patients. Messaging interventions such as the delivery of pop-up messages in electronic medical records to serve as reminders for physicians can be explored as a potential way to increase palliative care consultations for patients who need them.

Content Validity of a Conceptual Model of a Palliative Approach

BACKGROUND

The term "palliative approach" has emerged to connote healthcare activities provided consistent with the philosophy of palliative care, but not limited to specialized care providers or settings. A rigorous understanding of the palliative approach requires a conceptual model, which links the philosophy of palliative care to specific actions of practitioners, and is applicable to patients with any life-threatening illness, at any point on the disease trajectory, and provided by any care provider in any setting. This article proposes a conceptual model asserting that a palliative approach exists when care simultaneously addresses whole-person needs, enhances quality of life, and acknowledges mortality.

OBJECTIVE

To test the content validity of the proposed model against definitions of palliative care in existing literature.

DESIGN

Electronic and manual literature searches identified definitions of palliative care and palliative approach. Two authors independently conducted thematic analysis to assess congruence with the domains of the proposed conceptual model.

RESULTS

Nineteen definitions were identified. The three domains were represented in the majority: whole-person care (17/19), quality-of-life focus (17/19), and mortality acknowledgement (15/19). Published definitions also included other concepts, but only one of these (family within the unit of care) appeared in more than a few definitions.

CONCLUSIONS

The content validity of the proposed conceptual model is supported by the consistent presence of the three domains in published definitions. This conceptual model bridges philosophical definitions and clinician behavior and has potential to inform broad implementation of a palliative approach, at both clinic and system levels.

Update in Hospital Palliative Care: Symptom Management, Communication, Caregiver Outcomes, and Moral Distress

BACKGROUND

Updated knowledge of the palliative care (PC) literature is needed to maintain competency and best address the PC needs of hospitalized patients. We critiqued the recent PC literature with the highest potential to impact hospital practice.

METHODS

We reviewed articles published between January 2016 and December 2016, which were identified through a handsearch of leading journals and a MEDLINE search. The final 9 articles selected were determined by consensus based on scientific rigor, relevance to hospital medicine, and impact on practice.

RESULTS

Key findings include the following: scheduled antipsychotics were inferior to a placebo for nonterminal delirium; a low-dose morphine was superior to a weak opioid for moderate cancer pain; methadone as a coanalgesic improved high-intensity cancer pain; many hospitalized patients on comfort care still receive antimicrobials; video decision aids improved the rates of advance care planning (ACP) and hospice use and decreased costs; standardized, PC-led intervention did not improve psychological outcomes in families of patients with a chronic critical illness; caregivers of patients surviving a prolonged critical illness experienced high and persistent rates of depression; people with non-normative sexuality or gender faced additional stressors with partner loss; and physician trainees experienced significant moral distress with futile treatments.

CONCLUSIONS

Recent research provides important guidance for clinicians caring for hospitalized patients with serious illnesses, including symptom management, ACP, moral distress, and outcomes of critical illness.

Update in Hospice and Palliative Care

BACKGROUND/OBJECTIVE

The goal of this update in hospice and palliative care is to summarize and critique research published between January 1 and December 31, 2014 that has a high potential for impact on clinical practice.

DESIGN

To identify articles we hand searched 22 leading journals, the Cochrane Database of Systematic Reviews, and Fast Article Critical Summaries for Clinicians in Palliative Care. We also performed a PubMed keyword search using the terms "hospice" and "palliative care."

MEASUREMENTS

We ranked candidate articles based on study quality, appeal to a breadth of palliative care clinicians, and potential for impact on clinical practice.

RESULTS

In this manuscript we have summarized the findings of eight articles with the highest ratings and make recommendations for clinical practice based on the strength of the resulting evidence.

Experience in Strategic Networking to Promote Palliative Care in a Clinical Academic Setting in India

BACKGROUND

Palliative care in low and middle-income countries is a new discipline, responding to a greater patient need, than in high-income countries. By its very nature, palliative as a specialty has to network with other specialties to provide quality care to patients. For any medical discipline to grow as a specialty, it should be well established in the teaching medical institutions of that country. Data show that palliative care is more likely to establish and grow in an academic health care institution. It is a necessity that multiple networking strategies are adopted to reach this goal.

OBJECTIVES

(1) To describe a strategic approach to palliative care service development and integration into clinical academic setting. (2) To present the change in metrics to evaluate progress.

DESIGN AND SETTING

This is a descriptive study wherein, the different strategies that are adopted by the Department of Palliative Medicine for networking in an academic health care institution and outside the institution are scrutinized.

MEASUREMENT

The impact of this networking was assessed, one, at the level of academics and the other, at the level of service. The number of people who attended various training programs conducted by the department and the number of patients who availed palliative care service over the years were assessed.

RESULTS

Ten different strategies were identified that helped with networking of palliative care in the institution. During this time, the referrals to the department increased both for malignant diseases (52-395) and nonmalignant diseases (5-353) from 2000 to 2013. The academic sessions conducted by the department for undergraduates also saw an increase in the number of hours from 6 to 12, apart from the increase in a number of courses conducted by the department for doctors and nurses.

CONCLUSION

Networking is an essential strategy for the establishment of a relatively new medical discipline like palliative care in a developing and populous country like India, where the service is disproportionate to the demands.

Working together

Standards released by the American College of Surgeons Commission on Cancer program in 2012 call for all patients with cancer to have access to palliative care and for institutions to provide skilled and coordinated care as patients traverse through multiple healthcare settings. Many healthcare providers do not understand what palliative care can provide, or how it differs from hospice or end-of-life care. Oncology nurses and advanced practice nurses play an important role in educating healthcare providers, patients, and families about the role of palliative care and implementing it in the care of patients with cancer.

Socioeconomic Factors Associated With Posthospitalization Hospice Care Settings: A 5-Year Perspective

Investigating whether socioeconomic characteristics determine if hospice is received at home or in a medical facility is important to examine, considering most patients prefer to die at home. This study relied upon The State Inpatient Data of Nevada. A total of 19 206 discharges were analyzed from the data set between 2009 and 2013. The results indicate that increasingly patients are being discharged to home and overall socioeconomic characteristics appear to have less of an influence over whether hospice is received at home or in a medical facility. Further research on the perspectives of patients would provide insight into whether patients' preferences or socioeconomic characteristics are more influential on where hospice services are received.

Intervention to improve care at life's end in inpatient settings: the BEACON trial

BACKGROUND

Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.

OBJECTIVE

To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.

DESIGN

Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.

PARTICIPANTS

Six Veterans Affairs Medical Centers (VAMCs).

INTERVENTION

Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.

MAIN MEASURES

Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.

KEY RESULTS

Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.

CONCLUSIONS

This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

The sentinel hospitalization and the role of palliative care

With current healthcare reform and calls for improving care quality and safety, there is renewed emphasis on high-value care. Moreover, given the significant healthcare resource utilization for patients with chronically progressive illnesses or for patients at the end of life, innovative and efficient care delivery models are urgently needed. We propose here the concept of a sentinel hospitalization, defined as a transitional point in the patient's disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care. Hospitalists are well positioned to recognize a patient's sentinel hospitalization and use it as an opportunity for active integration of palliative care that provides high-quality and cost-saving care through its patient- and family-oriented approach, its interdisciplinary nature, and its focus on symptom control and care coordination.

Palliative care programs for patients with breast cancer: the benefits of home-based care

SUMMARY Improving breast cancer care means enhancing end-of-life care with specialized palliative care services. Palliative care embodies a holistic approach to care that focuses on symptom management of individuals with incurable diseases, whereas end-of-life care specifically focuses on a period of time, such as the last 6 months of life, where a rapid state of decline is often evident. The purpose of this article is to explore the benefits and limitations of end-of-life care provided in the hospital and community settings, with an emphasis on the benefits of home-based care. A key strength of home-based palliative care is the ability to expand the reach of palliative care to more cancer patients beyond residential hospice or hospital settings, which are limited in bed availability. The essential features of quality end-of-life services, regardless of setting, are care that offers seamless transitions, around-the-clock access to the same providers and an interdisciplinary, whole-person approach.

Impact of a home-based social welfare program on care for palliative patients in the Basque Country (SAIATU Program)

Background

SAIATU is a program of specially trained in-home social assistance and companionship which, since February 2011, has provided support to end-of-life patients, enabling the delivery of better clinical care by healthcare professionals in Osakidetza (Basque Health Service), in Guipúzcoa (Autonomous Community of the Basque Country).

In January 2012, a retrospective observational study was carried out, with the aim of describing the characteristics of the service and determining if the new social service and the associated socio-health co-ordination had produced any effect on the use of healthcare resources by end-of-life patients.

The results of a comparison of a cohort of cases and controls demonstrated evidence that the program could reduce the use of hospital resources and promote the continuation of living at home, increasing the home-based activity of primary care professionals.

The objective of this study is to analyse whether a program of social intervention in palliative care (SAIATU) results in a reduction in the consumption of healthcare resources and cost by end-of-life patients and promotes a shift towards a more community-based model of care.

Method/design

Comparative prospective cohort study, with randomised selection of patients, which will systematically measure patient characteristics and their consumption of resources in the last 30 days of life, with and without the intervention of a social support team trained to provide in-home end-of-life care.

For a sample of approximately 150 patients, data regarding the consumption of public healthcare resources, SAIATU activity, home hospitalisation teams, and palliative care will be recorded. Such data will also include information dealing with the socio-demographic and clinical characteristics of the patients and attending carers, as well as particular characteristics of patient outcomes (Karnofsky Index), and of the outcomes of palliative care received (Palliative Outcome Scale).

Ethical approval for the study was given by the Clinical Research Ethics Committee of Euskadi (CREC-C) on 10 Dec 2012.

Discussion

The results of this prospective study will assist in verifying or disproving the hypothesis that the in-home social care offered by SAIATU improves the efficiency of healthcare resource usage by these patients (quality of life, symptom control).

This project represents a dramatic advance with respect to other studies conducted to date, and demonstrates how, through the provision of personnel trained to provide social care for patients in the advanced stages of illness, and through strengthening the co-ordination of such social services with existing healthcare system resources, the resulting holistic structure obtains cost savings within the health system and improves the efficiency of the system as a whole.

Identifying patients suitable for palliative care--a descriptive analysis of enquiries using a Case Management Process Model approach

BACKGROUND

In Germany, case management in a palliative care unit was first implemented in 2005 at the Department of Palliative Medicine at the University Hospital Cologne. One of the purposes of this case management is to deal with enquiries from patients and their relatives as well as medical professionals. Using the Case Management Process Model of the Case Management Society of America as a reference, this study analysed (a) how this case management was used by different enquiring groups and (b) how patients were identified for case management and for palliative care services. The first thousand enquiries were analysed considering patient variables, properties of the enquiring persons and the content of the consultations.

RESULTS

Most enquiries to the case management were made by telephone. The majority of requests regarded patients with oncological disease (84.3 %). The largest enquiring group was composed of patients and relatives (40.8 %), followed by internal professionals of the hospital (36.1 %). Most of the enquiring persons asked for a patient's admission to the palliative care ward (46.4 %). The second most frequent request was for consultation and advice (30.9 %), followed by requests for the palliative home care service (13.3 %). Frequent reasons for actual admissions were the need for the treatment of pain, the presence of symptoms and the need for nursing care. More than half of the enquiries concerning admission to the palliative care ward were followed by an admission.

CONCLUSIONS

Case management has been made public among the relevant target groups. Case management as described by the Case Management Process Model helps to identify patients likely to benefit from case management and palliative care services. In addition, with the help of case management palliative patients may be allocated to particular health care services.

A model for emergency department end-of-life communications after acute devastating events--part II: moving from resuscitative to end-of-life or palliative treatment

The model for emergency department (ED) end-of-life communications after acute devastating events addresses decision-making capacity, surrogates, and advance directives, including legal definitions and application of these steps. Part II concerns communications moving from resuscitative to palliative and end-of-life treatments. After completing the steps involved in determining decision-making, emergency physicians (EPs) should consider starting palliative measures versus continuing resuscitative treatment. As communications related to these end-of-life decisions increasingly fall within the scope of emergency medicine (EM) practice, we need to become educated about and comfortable with them.

ACUTE center for eating disorders

BACKGROUND

While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

METHODS

We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.

RESULTS

From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.

DISCUSSION

Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Symptom management in gynecologic malignancies

Patients with gynecologic cancer experience significant symptom burden throughout their disease course and treatment, which negatively impacts their quality of life. The most common symptoms in gynecologic cancer include pain, fatigue, depression and anxiety. Palliative care, including symptom management, focuses on the prevention and relief of suffering and improvement in quality of life, irrespective of prognosis. In a comprehensive cancer care model, palliative care, including symptom management, is offered concurrently with anticancer therapies throughout the disease course, not just at the end of life and not only once curative attempts have been abandoned. Good symptom management begins with routine symptom assessment and use of a standardized screening tool can help identify patients with high symptom burden. Literature regarding epidemiology, assessment and management of pain, fatigue, nausea/vomiting, lymphedema, ascites, depression, anxiety and sexual dysfunction in gynecologic oncology patients will be reviewed in this article.

Partnerships between pediatric palliative care and psychiatry

Children with life-threatening illnesses and their families may face physical, emotional, psychosocial, and spiritual challenges throughout the children's course of illness. Pediatric palliative care is designed to meet such challenges. Given the psychosocial and emotional needs of children and their families it is clear that psychiatrists can, and do, play a role in delivering pediatric palliative care. In this article the partnership between pediatric palliative care and psychiatry is explored. The authors present an overview of pediatric palliative care followed by a summary of some of the roles for psychiatry. Two innovative pediatric palliative care programs that psychiatrists may or may not be aware of are described. Finally, some challenges that are faced in further developing this partnership and suggestions for future research are discussed.

Hospital do-not-resuscitate orders: why they have failed and how to fix them

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.

Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study

OBJECTIVE

This project sought to evaluate the impact of a hospital-based Palliative Care Consultation (PCC) service utilizing a common practice: the resident mortality review conference.

METHOD

Internal Medicine residents used a revised chart audit tool during the mortality review conference, which included domains described in the Clinical Practice Guidelines for Quality Palliative Care (2004). This study attempted to transform the common practice into a methodology for collecting data that could be used as a platform to assess the quality of hospital care near the end of life. In this review, the residents were asked not only "what care was delivered appropriately?" but "what could we have done?" to relieve the patient's and family's suffering.

RESULTS

The results showed that the mortality review process could be used to assess care at the end of life. It also showed that those patients who received a PCC received better care. Symptoms were addressed at a significantly higher rate for those patients who received a PCC than for those who did not. Specifically, these were symptoms of pain (75% vs. 51%, p < .0001), dyspnea (75% vs. 59%, p < 0.0001), nausea (28% vs. 18%, p < 0.0001), and agitation (53% vs. 33%, p < 0.0001).

SIGNIFICANCE OF RESULTS

The mortality review process was found to be valuable in assessing care delivery for patients near the end of life. The tool yielded results that were consistent with findings of other studies looking at pain and symptom management, advance care planning, and the rate of palliative care consults across major diagnostic categories, supporting the face validity of the mortality review process.

Clinically differentiating palliative care and hospice

Knowing the differences and potential benefits of hospice and palliative care can help healthcare professionals advocate for their patients and make proactive decisions about patient care. Providing admission into the appropriate program can facilitate symptom management and impart the best quality of life possible for this vulnerable population. Case studies will be used to differentiate hospice from palliative care, and the history, philosophy, availability, requirements, and barriers to receiving care will be discussed.

Partnerships between pediatric palliative care and psychiatry

Children with life-threatening illnesses and their families may face physical, emotional, psychosocial, and spiritual challenges throughout the children's course of illness. Pediatric palliative care is designed to meet such challenges. Given the psychosocial and emotional needs of children and their families it is clear that psychiatrists can, and do, play a role in delivering pediatric palliative care. In this article the partnership between pediatric palliative care and psychiatry is explored. The authors present an overview of pediatric palliative care followed by a summary of some of the roles for psychiatry. Two innovative pediatric palliative care programs that psychiatrists may or may not be aware of are described. Finally, some challenges that are faced in further developing this partnership and suggestions for future research are discussed.

Role of hospitalists in an offsite alternate care center (ACC) for pandemic flu

Recent concerns about an influenza pandemic have highlighted the need to plan for offsite Alternate Care Centers (ACCs). The likelihood of a successful response to patient surges will depend on the local health systems' ability to prepare well in advance of an influenza pandemic. Our health system has worked closely with our state's medical biodefense network to plan the establishment of an ACC for an influenza pandemic. As hospitalists have expanded their roles in their local health systems, they are poised to play a major role in planning for the next influenza pandemic. Hospitalists should work with their health system's administration in developing an ACC plan.

Research in Pediatric Palliative Care: Closing the Gap Between What Is and Is Not Known

Pediatric palliative care provides physical and psychosocial care to children with life-limiting illnesses and their families. Services are provided by physicians, nurses, volunteers, and other providers in a myriad of settings. Over the past 30 years, a portfolio of research has amassed on palliative care. Yet, much remains unknown, particularly about pediatric palliative care. This article is the first in a series and it provides a general overview of what is known and unknown about the provision and need for pediatric palliative care. Subsequent articles will focus on specific topics such as decision making and support care. The purpose of this series is to inform and promote discussion about research in pediatric palliative care.

Variability in access to hospital palliative care in the United States

BACKGROUND

Hospital palliative care programs provide high-quality, comprehensive care for seriously ill patients and their families.

OBJECTIVE

To examine geographic variation in patient and medical trainee access to hospital palliative care and to examine predictors of these programs.

METHODS

Primary and secondary analyses of national survey and census data. Hospital data including hospital palliative care programs were obtained from the American Hospital Association (AHA) Annual Survey Databasetrade mark for fiscal year 2006 supplemented by mailed surveys. Medical school-affiliated hospitals were obtained from the American Association of Medical Colleges, Web-site review, and telephone survey. Health care utilization data were obtained from the Dartmouth Atlas of Health Care 2008. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of hospital palliative care.

RESULTS

A total of 52.8% of hospitals with 50 or more total facility beds reported hospital palliative care with considerable variation by state; 40.9% (144/352) of public hospitals, 20.3% (84/413) of for-profit hospitals, and 28.8% (160/554) of Medicare sole community providers reported hospital palliative care. A total of 84.5% of medical schools were associated with at least one hospital palliative care program. Factors significantly associated (p < 0.05) with hospital palliative care included geographic location, owning a hospice program, having an American College of Surgery approved cancer program, percent of persons in the county with a university education, and medical school affiliation. For-profit and public hospitals were significantly less likely to have hospital palliative care when compared with nonprofit institutions. States with higher hospital palliative care penetration rates were observed to have fewer Medicare hospital deaths, fewer intensive care unit/cardiac care unit (ICU/CCU) days and admissions during the last 6 months of life, fewer ICU/CCU admission during terminal hospitalizations, and lower overall Medicare spending/enrollee.

DISCUSSION

This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study.

Expanding the roles of hospitalist physicians to include public health

Several years after the inception of the hospitalist movement, hospitalist roles have evolved in breadth and sophistication. Although public health is not formally recognized or previously described as an arena for hospitalists, hospitalists are often engaged in public health practice. This article attempts to alert hospitalists to the potential to make contributions to the field of public health and defines the public health skills that can positively affect the lives of their patients and the communities they serve. In a public health role, hospitalists may improve the quality of inpatient care. This article reviews how public health and hospital-based practices have already intersected and proposes further development within this discipline. In our ever-changing health care system, hospitalists play key roles in the central public health domains of assessment, assurance, and policy development. Insightful hospitalists will recognize and embrace these responsibilities in caring for patients and society.