EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Filipino American and Korean American Patients

As of 2019, there are 4.2 million Filipino Americans (FAs) and 1.9 million Korean Americans (KAs) in the United States, largely concentrated in New York, California, Texas, Illinois, and Washington. In both populations, similar to the broader U.S. culture, one can find health literacy gaps around understanding and utilizing palliative care. In this article, we provide 10 cultural pearls to guide clinicians on how to sensitively approach FA and KA groups when addressing palliative and end-of-life (EOL) discussions. We fully celebrate that every person is an individual and care should be tailored to each person's goals, values, and preference. In addition, there are several cultural norms that, when appreciated and celebrated, may help clinicians to improve serious illness care and EOL discussions for members of these populations.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients

The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.

An Intensive Longitudinal Assessment Approach to Surveilling Trajectories of Burnout over the First Year of the COVID Pandemic

Frontline clinicians responding to the COVID-19 pandemic are at increased risk of burnout, but less is known about the trajectory of clinician burnout as caseloads increase and decrease. Personal and professional resources, including self-efficacy and hospital support, can attenuate the risk of burnout. Yet, empirical data documenting how burnout and resources changed as the pandemic waxed and waned are limited. This intensive longitudinal prospective study employed ecological momentary assessment methods to examine trajectories of burnout and resources over the pandemic's first year in a New York City hospital. A 10-item survey was emailed every 5 days to frontline clinicians (physicians, nurses, and physician assistants). The primary outcome was a single-item validated measure of burnout; predictors included daily hospital COVID-19-related caseloads and personal and professional resources. Clinicians (n = 398) completed the initial survey and an average of 12 surveys over the year. Initially, 45.3% of staff reported burnout; over the year, 58.7% reported burnout. Following the initial COVID peak, caseloads declined, and burnout levels declined. During the second wave of COVID, as caseloads increased and remained elevated and personal and professional resource levels decreased, burnout increased. This novel application of intensive longitudinal assessment enabled ongoing surveillance of burnout and permitted us to evaluate how fluctuations in caseload intensity and personal and professional resources related to burnout over time. The surveillance data support the need for intensified resource allocation during prolonged pandemics.

[Effect of EIT-guided individualized PEEP setting on the incidence of hypoxemia in elderly patients undergoing robot-assisted radical prostatectomy]

Objective: To investigate the effect of individualized positive end expiratory pressure (PEEP) setting guided by chest electrical impedance tomography (EIT) on the incidence of hypoxemia in elderly patients undergoing robot-assisted radical prostatectomy in the post anesthesia care unit (PACU). Methods: From September 2020 to October 2021, sixty elderly patients, with the American Association of Anesthesiologists (ASA) of Grade Ⅰ to Ⅲ, who underwent selective robot-assisted radical prostatectomy under general anesthesia in the Cancer Hospital Affiliated to Fudan University were selected. The participants were divided into two groups by the minimum randomized grouping method: EIT-PEEP group (EP group, n=30) and fixed PEEP group (FP group, n=30). After completion of tracheal intubation and establishment of pneumoperitoneum flexion posture, the individualized PEEP setting was guided by EIT in EP group, and the PEEP setting in FP group was 5 cmH₂O (1 cmH₂O=0.098 kPa) to the end of operation. During the operation, the ventilation mode of pressure regulation volume control was adopted. The driving pressure, dynamic lung compliance (Cdyn), oxygenation index and hemodynamics were recorded at 5 min (T₁), 30 min (T₂), 60 min (T₃) after PEEP setting and at the time of tracheal catheter removal (T₄) in both groups. The primary end point was the incidence of hypoxemia in PACU after extubation. Results: The incidence of hypoxemia after extubation was 3.3% (1/30) in EP group and 26.7% (8/30) in FP group (P=0.030). The difference of driving pressure between the two groups at T₂ [(13.1±2.4) cmH₂O vs (14.9±2.9) cmH₂O, P=0.012], T₃ [(12.7±2.4) cmH₂O vs (15.6±2.8) cmH₂O, P<0.001] was statistically significant. In EP group, Cdyn was improved at T₂ [(38.4±7.2) ml/cmH₂O vs (31.9±5.2) ml/cmH₂O, P=0.006] and T₃ [(37.5±9.0) ml/cmH₂O vs (30.4±5.9) ml/cmH₂O, P=0.001]. In EP group, PaO₂/FiO₂ increased at T₁ [(465.7±84.5) mmHg vs (383.5±58.0) mmHg, 1 mmHg=0.133 kPa, P<0.001], T₂ [(504.7±105.8) mmHg vs (418.9±73.7) mmHg, P=0.001], T₃ [(520.7±92.2) mmHg vs (423.2±90.7) mmHg, P<0.001], T₄ [(368.7±42.0) mmHg vs (339.5±54.9) mmHg, P=0.024]. Conclusion: The individualized PEEP setting guided by EIT can reduce the incidence of hypoxemia in elderly patients undergoing robot assisted radical prostatectomy in PACU.

Top Ten Tips Palliative Care Clinicians Should Know About Navigating the Needs of Adults with Intellectual Disabilities

As many people with intellectual disabilities (ID) live longer, the need for access to quality palliative care (PC) rises. People with ID realize significant barriers and inequities in accessing health care and PC. The need for integrated disability and PC services with extensive collaboration is great. The following tips are for PC clinicians caring for people with ID, their families, caregivers, and the community. While patient-centered care is difficult to distill into "tips," this article, written by an interdisciplinary team of PC and ID specialists, offers resources and references to improve the care provided to people with ID and serious illnesses.

Factors Associated with Burnout among Resident Physicians Responding to the COVID-19 Pandemic: A 2-Month Longitudinal Observation Study

BACKGROUND

Burnout during residency may be a function of intense professional demands and poor work/life balance. With the onset of the COVID-19 pandemic, NYC hospital systems were quickly overwhelmed, and trainees were required to perform beyond the usual clinical duties with less supervision and limited education.

OBJECTIVE

The present longitudinal study examined the effects of COVID-19 caseload over time on burnout experienced by resident physicians and explored the effects of demographic characteristics and organizational and personal factors as predictors of burnout severity.

METHODS

This study employed a prospective design with repeated measurements from April 2020 to June 2020. Participants were surveyed about their well-being every 5 days. Predictors included caseload, sociodemographic variables, self-efficacy, hospital support, perceived professional development, meaning in work, and postgraduate training level.

RESULTS

In total, 54 resident physicians were recruited, of whom 50% reported burnout on initial assessment. Periods of higher caseload were associated with higher burnout. PGY-3 residents reported more burnout initially but appeared to recover faster compared to PGY-1 residents. Examined individually, higher self-efficacy, professional development, meaningful work, and hospital support were associated with lower burnout. When all four predictors were entered simultaneously, only self-efficacy was associated with burnout. However, professional development, meaningful work, and hospital support were associated with self-efficacy.

CONCLUSION

Burnout among residency is prevalent and may have implications for burnout during later stages of a physician's career. Self-efficacy is associated with lower burnout and interventions to increase self-efficacy and the interpersonal factors that promote self-efficacy may improve physician physical and emotional well-being.

Associations of Intellectual Disability with Cardiopulmonary Resuscitation and Endotracheal Intubation at End of Life

Background: Little is known about end-of-life intensive care provided to patients with intellectual disabilities (ID). Objectives: To identify differences in receipt of end-of-life cardiopulmonary resuscitation (CPR) and endotracheal intubation among adult patients with and without ID and examine whether do-not-resuscitate orders (DNRs) mediate associations between ID and CPR. Design: Exploratory matched cohort study using medical records of inpatient decedents treated between 2012 and 2018. Results: Patients with ID (n = 37) more frequently received CPR (37.8% vs. 21.6%) and intubation (78.4% vs. 47.8%) than patients without ID (n = 74). In multivariable models, ID was associated with receiving CPR (relative risk [RR] = 2.92, 95% confidence interval = 1.26-6.78, p = 0.012), but not intubation. Patients with ID less frequently had a DNR placed (67.6% vs. 91.9%), mediating associations between ID and CPR. Conclusions: In this pilot study, ID was associated with increased likelihood of receiving end-of-life CPR, likely due to lower utilization of DNRs among patients with ID. Further research is needed to confirm these results.

Questioning Capacity in an Elderly Jamaican Man with Terminal Cancer Exhibiting Near-Death Awareness: A Case Report and Review of Literature

Background: Near-death awareness (NDA) refers to visions and dreams commonly experienced by terminally ill individuals within months to hours before death. Methods: A case report of a 68-year-old Jamaican male diagnosed with advanced cholangiocarcinoma, who experienced visions of his deceased mother during hospitalization. Results: This article discusses how to differentiate NDA from delirium, core components for determining decisional capacity, and how clinicians can use a cultural guide to optimize patient-centered care. Conclusion: Improved recognition of NDA may promote cultural humility/competency and help to differentiate NDA from an underlying medical/psychiatric condition. It may assist the clinician in understanding the significance of NDA and the comfort and meaning these experiences may hold for both the individual and their family.

Heart to Heart Cards: A Novel, Culturally Tailored, Community-Based Advance Care Planning Tool for Chinese Americans

CONTEXT

A paucity of literature describes the growing Chinese American community's end-of-life (EOL) priorities and preferences.

OBJECTIVE

Develop a culturally-tailored advance care planning (ACP) tool to understand the EOL preferences of this underserved minority group.

METHODS

Informed by the Cultural Appropriateness Theory, the Chinese American Coalition for Compassionate Care (CACCC) developed Heart to Heart (HTH) Cards using a 3-step approach. First, CACCC created and refined a list of bilingual, culturally relevant EOL issues. Next, CACCC organized the EOL issues into a card deck. Finally, CACCC developed a unique playstyle of the cards-the HTH Café. From 2014-2019, CACCC recruited Chinese American volunteers and participants for HTH Cafés. Following each Café, participants completed an anonymous survey describing their sociodemographics, top 3 cards, and café evaluation.

RESULTS

The 54 HTH Cards were organized into 4 suits (spiritual, physical, financial/legal, and social). Each card displayed a culturally-tailored EOL issue in English and Chinese. Playstyles included one-on-one and group formats (ie. HTH Café). CACCC volunteers conducted 316 HTH Cafés for 2,267 Chinese American adults. Most participants were female (61.6%), between 18-50 years old (56.7%), lived in California (80.2%) and born in Asia (74.3%). The top priority (25.5%) was "If I'm going to die anyway, I don't want to be kept alive by machines." Participants thought the session was pleasant (99.5%) and expressed intent to complete advance directives (86.5%).

CONCLUSION

HTH Cards represents the first, theory-driven, culturally-tailored ACP tool for Chinese Americans. More research is needed to establish its impact on ACP conversations and outcomes.

Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

BACKGROUND

Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.

AIM

Examine the relationship between dementia, DNR timing, and end-of-life care intensity.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.

RESULTS

Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.

CONCLUSIONS

Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

A Comprehensive Approach to Palliative Care during the Coronavirus Pandemic

Context: The COVID-19 pandemic resulted in a surge of critically ill patients that strained health care systems throughout New York City in March and April of 2020. At the peak of the crisis, consults for palliative care increased four- to sevenfold at NewYork-Presbyterian (NYP), an academic health care system with 10 campuses throughout New York City. We share our challenges, solutions, and lessons learned to help peer institutions meet increased palliative care demands during future crises and address pre-existing palliative care subspecialist shortages during nonpandemic times. Methods: In response to the increased demand, palliative care physician and administrative leadership at NYP piloted multiple creative care models to expand access to palliative care outpatient and inpatient services. The care models included virtual outpatient management of existing patients, embedded palliative care staff, education for providers, multidisciplinary family support, hospice units (which allowed for family visitation), and team expansion through training other disciplines (primarily psychiatry) and deploying an ePalliative Care service (staffed by out-of-state volunteers). Conclusion: Our comprehensive response successfully expanded the palliative care team's reach, and, at the height of the pandemic, allowed our teams to meet the increased demand for palliative care consults. We learned that flexibility and adaptability were critical to responding to a rapidly evolving crisis. Physician and family feedback and preliminary data suggest that virtual outpatient visits, embedded staff, hospice units, and team expansion through training other disciplines and deploying ePalliative Care services were impactful interventions.

Can Orthodox Jewish Patients Undergo Palliative Extubation? A Challenging Ethics Case Study

According to Jewish law/ethics, continuous life-sustaining therapy may not be withdrawn after its introduction, unless the patient has improved and no longer has a medical indication for the treatment. We report the case of an 88-year-old Orthodox Jewish patient, on invasive mechanical ventilation, with severe anoxic brain injury after multiple cardiac arrests. Although the patient's son informed the palliative care team that his father did not want to be in pain or to linger in a vegetative state when terminally ill, the mechanical ventilation was keeping him alive with a poor neurological prognosis. Additionally, the patient had previously stated his wish to observe Orthodox Jewish principles regarding end-of-life care. After extensive discussion, the family Rabbi clarified that it would be acceptable to withdraw mechanical ventilation if there were a "reasonable expectation" he would breathe on his own for a "reasonable amount of time." Thus, if the patient's death were to occur, it would not be an immediate consequence the normal ventilator weaning process. Following intermediation by the hospital Rabbi, the definition of what would be a "reasonable expectation" and "reasonable amount of time" was established by the family Rabbi as "over 50%" and "on the order of hours," respectively. Following pulmonary consultation, the patient underwent palliative extubation and, 12 hours after the procedure, died comfortably surrounded by the family. In conclusion, the collaborative and interdisciplinary work among the family Rabbi, hospital Rabbi, and the various medical teams allowed the development of a plan that met all of the patient's personal and religious wishes and beliefs.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience (EMPOWER) among Surrogate Decision-Makers of ICU Patients: study protocol for a randomized controlled trial

Background

Critical illness increases the risk for poor mental health outcomes among both patients and their informal caregivers, especially their surrogate decision-makers. Surrogates who must make life-and-death medical decisions on behalf of incapacitated patients may experience additional distress. EMPOWER (Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience) is a novel cognitive-behavioral, acceptance-based intervention delivered in the intensive care unit (ICU) setting to surrogate decision-makers designed to improve both patients’ quality of life and death and dying as well as surrogates’ mental health.

Methods

Clinician stakeholder and surrogate participant feedback (n = 15), as well as results from an open trial (n = 10), will be used to refine the intervention, which will then be evaluated through a multisite randomized controlled trial (RCT) (n = 60) to examine clinical superiority to usual care. Feasibility, tolerability, and acceptability of the intervention will be evaluated through self-report assessments. Hierarchical linear modeling will be used to adjust for clustering within interventionists to determine the effect of EMPOWER on surrogate differences in the primary outcome, peritraumatic stress. Secondary outcomes will include symptoms of post-traumatic stress disorder, prolonged grief disorder, and experiential avoidance. Exploratory outcomes will include symptoms of anxiety, depression, and decision regret, all measured at 1 and 3 months from post-intervention assessment. Linear regression models will examine the effects of assignment to EMPOWER versus the enhanced usual care group on patient quality of life or quality of death and intensity of care the patient received during the indexed ICU stay assessed at the time of the post-intervention assessment. Participant exit interviews will be conducted at the 3-month assessment time point and will be analyzed using qualitative thematic data analysis methods.

Discussion

The EMPOWER study is unique in its application of evidence-based psychotherapy targeting peritraumatic stress to improve patient and caregiver outcomes in the setting of critical illness. The experimental intervention will be strengthened through the input of a variety of ICU stakeholders, including behavioral health clinicians, physicians, bereaved informal caregivers, and open trial participants. Results of the RCT will be submitted for publication in a peer-reviewed journal and serve as preliminary data for a larger, multisite RCT grant application.

Trial registration

ClinicalTrials.gov, NCT03276559. Retrospectively registered on 8 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3515-0) contains supplementary material, which is available to authorized users.

Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout

Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (β = 0.55, SE = 0.12, p < 0.001), avoiding the patient (β = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (β = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.

To Code or Not To Code: Teaching Multidisciplinary Clinicians to Conduct Code Status Discussions

Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes.

Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities

Background: The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. Aim: The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. Methods: A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. Results: The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p=0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p<0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Conclusion: Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU.

Contexte: Il existe très peu de publications décrivant l'attitude des asiatiques envers l'intervention des spécialistes en soins palliatifs dans le service de soins intensifs. But: Cette étude avait pour but de comparer les résultats obtenus chez les asiatiques et d'autres groupes ethniques après l'intervention de ces spécialistes auprès des patients et de leur famille dans le service de soins intensifs. Méthode: On a fait l'analyse rétrospective des dossiers de tous les patients ayant été rencontrés par l'équipe de soins palliatifs; les résultats de l'analyse portaient sur la fréquence des traitements de prolongation de vie, les directives de fin de vie, et les préférences des patients en ce qui avait trait aux soins de fin de vie. Résultats: L'équipe de soins palliatifs a évalué les dossiers de 119 patients (46,2 pourcent d'origine caucasienne, 27,2 pourcent d'origine asiatique, et 26,1 pourcent de diverses origines). Trente-six pourcent des asiatiques, 49 pourcent des caucasiens, et 28,6 pourcent des autres ethniques (p=19) avaient déjà choisi leur mandataire légal. L'équipe de soins palliatifs a augmenté le recours aux directives de fin de vie par plus de 40 pourcent dans tous les groupes (p=<0,001). Il n'y avait aucune différence entre ces groupes quant au recours aux traitements de fin de vie et aux mesures de confort du patient. Conclusion: Suite à une rencontre avec l'équipe de soins palliatifs, les asiatiques, tout comme les autres groupes ethniques, sont tout autant susceptibles de décider de leurs traitements de fin de vie et de recourir aux mesures de confort et aux directives préalables.

Association of Perceived Futile or Potentially Inappropriate Care With Burnout and Thoughts of Quitting Among Health-Care Providers

BACKGROUND

Futile or potentially inappropriate care (futile/PIC) has been suggested as a factor contributing to clinician well-being; however, little is known about this association.

OBJECTIVE

To determine whether futile/PIC provision is associated with measures of clinician well-being.

DESIGN

Cross-sectional, self-administered, online questionnaire.

SETTING

Two New York City Hospitals.

PARTICIPANTS

Attending physicians, residents, nurses, and physician assistants in the fields of internal medicine, surgery, neurology, or intensive care.

EXPOSURE(S)

Provision of perceived futile/PIC.

MEASUREMENTS

Main outcomes included (1) clinician burnout, measured using the Physician Worklife Study screen; (2) clinician depression, measured using the Patient Health Questionnaire; and (3) intention to quit, measured using questions assessing thoughts of quitting and how seriously it is being considered.

RESULTS

Of 1784 clinicians who received surveys, 349 participated. Across all clinicians, 91% reported that they either had or had possibly provided futile/PIC to a patient. Overall, 43.4% of clinicians screened positive for burnout syndrome, 7.8% screened positive for depression, and 35.5% reported thoughts of leaving their job as a result of futile/PIC. The amount of perceived futile/PIC provided was associated with burnout (odds ratio [OR] 3.8 [16-30 patients vs 1-2 patients]; 95% confidence interval [CI]: 1.1-12.8) and having thoughts of quitting (OR, 7.4 [16-30 patients vs 1-2 patients]; 95% CI: 2.0-27), independent of depression, position, department, and the number of dying patients cared for.

CONCLUSIONS

A large majority of clinicians report providing futile/PIC, and such care is associated with measures of clinician well-being, including burnout and intention to quit.

[Study of the effects of hydromorphone on emergence agitation of children anesthetized by sevoflurane]

Objective: To observe the effect of hydromorphone on emergence agitation of children anesthetized by Sevoflurane. Methods: One hundred patients without any analgetic, aged 3 to 7 years, ASA Ⅰ-Ⅱ, undergoing strabismus surgery in Beijing Tongren Hospital from March, 2017 to December, 2017 were selected and they were randomly divided into two groups(n=50), H group and F group by random number table. After standardized tidal volume method induction by 8% sevoflurane and oxygen, suiltable laryngeal mask was inserted, and each patient was left spontaneously breathing anesthetized by 2.5%-3.0% sevoflurane.Ten minutes before the surgery, patients in H group were administered a dose of 0.01 mg/kg hydromorphone (diluted to 5 ml with normal saline) by pump control injection in 10 min, whereas patients in F group administered a dose of 1 μg/kg fentanyl in the same way. After the surgery , the patient was sent to postanesthesia care unit. A nurse who was blinded measured the vital signs, pediatric anesthesia emergence delirium(PAED) score, face legs activity cry consolability behavioral pain assessment tool(FLACC) score, the time of opening the eyes and departing from postanesthesia care unit(PACU), and the occurence rates of hypoxemia, swirl or nausea, drowsiness, and other scores. Results: The incidence of emergence agitation(EA) in H group was lower than in F group, whether EA was defined as PAED>10 (18.0% vs 28.0%, P>0.05) or PAED>12(12.0% vs 24.0%, P>0.05), there were not significant differences between them. The ratio of patients whose PAED>15 in F group was 12.0%, while the ratio of H group was 0, there was significant difference between the two groups(P=0.027). The occurrence rates of swirl, glossocoma in H group were 0 and 10.0% while those of F group were all 6.0%, there were no significant differences between the two groups(P>0.05). Conclusions: Comparing with fentanyl, hydromorphone can prevent the occurrence rate of EA of the children anesthetized by sevoflurane equally, even decrease the occurrence rate of the severe EA more observably, and reduce postoperation pain more significantly with less occurrence rate of swirl or nausea. Glossocoma need be paid attention to when HM is administered.

Palliative Care in New York State Nursing Homes: A Descriptive Study

Objective:

To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS).

Measurements:

A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions.

Results:

Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC.

Conclusion:

There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.

Asymptomatic rectal colonization with carbapenem-resistant Enterobacteriaceae and Clostridium difficile among residents of a long-term care facility in New York City

BACKGROUND

Residents of long-term care facilities (LTCFs) are at increased risk for colonization and development of infections with multidrug-resistant organisms. This study was undertaken to determine prevalence of asymptomatic rectal colonization with Clostridium difficile (and proportion of 027/NAP1/BI ribotype) or carbapenem-resistant Enterobacteriaceae (CRE) in an LTCF population.

METHODS

Active surveillance was performed for C difficile and CRE rectal colonization of 301 residents in a 320-bed (80-bed ventilator unit), hospital-affiliated LTCF with retrospective chart review for patient demographics and potential risk factors.

RESULTS

Over 40% of patients had airway ventilation and received enteral feeding. One-third of these patients had prior C difficile-associated infection (CDI). Asymptomatic rectal colonization with C difficile occurred in 58 patients (19.3%, one-half with NAP1+), CRE occurred in 57 patients (18.9%), and both occurred in 17 patients (5.7%). Recent CDI was significantly associated with increased risk of C difficile ± CRE colonization. Multivariate logistic regression analysis revealed presence of tracheostomy collar to be significant for C difficile colonization, mechanical ventilation to be significant for CRE colonization, and prior CDI to be significant for both C difficile and CRE colonization.

CONCLUSIONS

The strong association of C difficile or CRE colonization with disruption of normal flora by mechanical ventilation, enteral feeds, and prior CDI carries important implications for infection control intervention in this population.

Schwannomas of female genitalia from a gynaecologist's perspective: report of two cases and review of the literature

BACKGROUND

Pelvic schwannomas are extremely rare. However, when located in the pelvic cavity, schwannomas are often encountered by a gynaecologist, not a general surgeon, and are misdiagnosed as gynaecologic masses.

CASE REPORT

Here, the authors present two cases of pelvic schwannomas that were preoperatively misdiagnosed as broad ligament fibroid. One schwannoma occurred completely in the left broad ligament and was resected by laparoscopy without any complications. The other lesion was located in the retroperitoneum and had densely adhered to the surrounding tissues; this lesion was excised by laparotomy with considerable blood loss.

CONCLUSIONS

Schwannomas of female genitalia are very scarce and difficulty to diagnose preoperatively. Literature review revealed 63 schwannomas arising from the female genital tract in total, 73.02% (46 cases) were located in the lower genital tract, and 26.98% (17 cases) were located in upper genital tract. The treatment modality is unique depending on the location of the tumor. Complete excision is benefical for diagnosis and treatment. The procedure can be performed safely under laparoscopy.

Impact of a Palliative Care Program on Tracheostomy Utilization in a Community Hospital

BACKGROUND

Tracheostomies are typically provided to wean patients off the ventilator. However, in many circumstances tracheostomies are placed in patients who are at the end of their life with little hope of meaningful recovery. Palliative care teams decrease utilization of aggressive medical interventions in patients who are at the end of life.

OBJECTIVE

The study objective was to determine the impact of a palliative care team on tracheostomy utilization in a community hospital setting.

METHODS

The study was a four-year retrospective analysis of adult patients undergoing elective tracheostomy two years before and after the establishment of a palliative care program. The study in an ethnically diverse community hospital included patients older than 18 years old, with patients undergoing a tracheostomy due to trauma excluded. Before and after comparisons were made of demographics, in-hospital mortality, length of stay, and discharge status of patients undergoing tracheostomy.

RESULTS

Seven hundred ninety patients undergoing tracheostomy were identified (n = 406, n = 384 before and after September 10, 2010, respectively). Patients were ethnically diverse (Caucasian 43%, Asian 23%, African American 11%, Hispanic 7%). The number of hospital admissions slightly increased during these two time periods (n = 58,926; n = 60,662, respectively). There were no statistical differences in age (73 versus 72, p = 0.827); gender (n = 218 [54%] versus n = 217 [57%] male, p = 0.426); or race (n = 187 [46%] versus n = 150 [39%] Caucasian, p = 0.073) in the two time periods. Patients who underwent tracheostomy after a palliative care service was established had less incidence of comorbid disease (Charlson Comorbidity Index score [CCIS]: 2 versus 3, p = 0.025); lower inpatient mortality (n = 107 [28%] versus n = 148 [37%], p = 0.009]); greater discharge to home or rehabilitation (n = 262 [68%] versus n = 249 [62%], p = 0.01); and lower rates of palliative weaning from mechanical ventilation (n = 61[16%] versus n = 113 [28%], p < 0.001).

CONCLUSIONS

In an ethnically diverse community hospital, the institution of a palliative care program appears to have improved patient selection for tracheostomy with lower rates of inpatient mortality, improved rates of home discharge, and lower rates of palliative weaning from mechanical ventilation.

Cognitive changes after surgery in the elderly: does minimally invasive surgery influence the incidence of postoperative cognitive changes compared to open colon surgery?

BACKGROUND

Postoperative delirium in the elderly is a growing concern. Data regarding significant differences in postoperative cognitive dysfunction (POCD) in elderly persons undergoing laparoscopic versus open colon resection are not well established.

OBJECTIVES

The goal of this study was to compare the incidence of POCD in laparoscopic versus open colon surgery in an elderly population.

DESIGN AND SETTING

A prospective nonrandomized pilot study was conducted at an urban tertiary care hospital.

PARTICIPANTS

The study included patients aged 65 years and above, without documented dementia who underwent elective colon surgery.

MEASUREMENTS

We collected demographic and clinical data, including age, sex, polypharmacy, and comorbidities. The subjects underwent pre- and postoperative Cambridge Neuropsychological Test Automated Battery (CANTAB) testing. Worsening individual scores from the Paired Associated Learning (PAL) and Spatial Working Memory (SWM) portions of CANTAB determined the presence of POCD. Inflammatory cytokine (i.e., IL-6) levels were measured pre- and postoperatively.

RESULTS

We enrolled 44 subjects (26 laparoscopic and 18 open surgery). The two groups did not differ significantly in age, sex, polypharmacy, and comorbidities. The average incidence of POCD was 47%. PAL scores worsened in 12/23 (52%) in the laparoscopic group and in 7/15 (47%) in the open group. These group differences lacked statistical significance (p = 0.75). SWM scores worsened in 14/25 (56%) in the laparoscopic group and in 6/18 (33%) in the open group, which was also not statistically significant (p = 0.12). No age difference occurred between the 'worsened scores' group and 'stable scores' group, and older age was not associated with POCD. IL-6 levels were higher in the open versus the laparoscopic group (p < 0.0001).

CONCLUSION

In this pilot study, the average incidence of POCD was not statistically different between elderly subjects undergoing open versus laparoscopic surgery. Age did not influence the occurrence of POCD. Although inflammatory markers were significantly higher in the open group, consistent with a higher degree of stress response, this group did not have higher rates of delirium. This association is worth to be investigated in a larger sample.

Your postop patient is confused and agitated--next steps?

Your older patient exhibits signs and symptoms that suggest delirium. Here's how to best handle this complication.

Just ask: hospice familiarity in Asian and Hispanic adults

CONTEXT

Previous research documents the under-utilization of hospice services by minority ethnic groups, but less data exist for Asian and Hispanic Americans. It is unclear whether these low utilization rates are a result of attitudinal or information barriers, or both.

OBJECTIVES

To examine self-reported familiarity and attitudes toward hospice among Asian and Hispanic groups in ethnically diverse Queens County, NY.

METHODS

We surveyed diverse adults during health fairs, at senior centers, and church programs directed at ethnic populations. Respondents completed surveys in their preferred language: Spanish, Chinese (Mandarin), and Korean. Analysis of variance was used to compare continuous variables among language groups; Fisher's exact test compared categorical variables.

RESULTS

A total of 604 community adults were surveyed: 99 Chinese, 349 Korean, 156 Spanish. Respondents were mostly female, average age 53 years. Familiarity with hospice varied significantly among the groups (P < 0.001) and was lower in the Hispanic (16%) and higher in the Chinese (45%) and Korean (56%) groups. Personal experiences with hospice were low (8-16%) in all groups. A majority (75-94%) responded they would share hospice information with loved ones, but the Hispanic group was significantly less likely to do so compared with Chinese and Korean Americans. Between 74 and 95% reported willingness to receive future information about hospice, but the Korean group was significantly less likely to want information.

CONCLUSION

When surveyed in their preferred language, Asian and Hispanic adults reported variable levels of familiarity with hospice services. Most responded positively to receiving future information and would tell friends and family members about hospice.

Prospective evaluation of low-dose ketoconazole plus hydrocortisone in docetaxel pre-treated castration-resistant prostate cancer patients

Background

Ketoconazole is a well-known CYP-17-targeted systemic treatment for castration-resistant prostate cancer (CRPC). However, most of the published data has been in the pre-chemotherapy setting; its efficacy in the post-chemotherapy setting has not been as widely described. Chemotherapy-naïve patients treated with attenuated doses of ketoconazole (200-300 mg three times daily) had prostate specific antigen (PSA) response rate (greater than 50% decline) of 21% to 62%. We hypothesized that low-dose ketoconazole would likewise possess efficacy and tolerability in the CRPC post-chemotherapy state.

Methods

Men with CRPC and performance status (PS) 0-3, adequate organ function and who had received prior docetaxel were treated with low-dose ketoconazole (200 mg PO three times daily) and hydrocortisone (20 mg PO qAM and 10 mg PO qPM) until disease progression. Primary endpoint was PSA response rate (greater than 50% reduction from baseline) where a PSA response rate of 25% was to be considered promising for further study (versus a null rate of less than 5%); 25 patients were required. Secondary endpoints included PSA response greater than 30% from baseline, progression-free survival (PFS), duration of stable disease, and evaluation of adverse events (AEs).

Results

Thirty patients were accrued with median age of 72 years (range 55-86) and median pre-treatment PSA of 73 ng/ml (range 7-11,420). Twenty-nine patients were evaluable for response and toxicity. PSA response (>50% reduction) was seen in 48% of patients; PSA response (>30% reduction) was seen in 59%. Median PFS was 138 days; median duration of stable disease was 123 days. Twelve patients experienced grade 3 or 4 AEs. Of the 17 grade 3 AEs, only 3 were attributed to treatment. None of the 2 grade 4 AEs was considered related to treatment.

Conclusions

In docetaxel pre-treated CRPC patients, low-dose ketoconazole and hydrocortisone is a well-tolerated, relatively inexpensive and clinically active treatment option. PSA response to low-dose ketoconazole appears historically comparable to that of abiraterone in this patient context. A prospective, randomized study of available post-chemotherapy options is warranted to assess comparative efficacy.

Cross-cultural health care for older adults: strategies for pharmacists

The United States population not only is aging, but also becoming more ethnically diverse. Approximately half of elders who take medications find adherence challenging, and cultural diversity is one of the variables that may affect adherence. By better understanding patients' cultural perspectives, senior care pharmacists can more effectively address their medication management needs; failure to recognize these differences may contribute to misunderstanding or miscommunication that may affect treatment. When a patient does not adhere to prescribed medications, explore reasons and feelings. Different ethnic groups have varying communication styles and also seek different degrees of family involvement in diagnosis and treatment. Some mistrust in Western health care, choose to use herbs and nonpharmacologic agents, and have different time orientation that may affect adherence. Senior pharmacists have an active role in screening, evaluation, and counseling elderly, ethnically diverse patients. Applying general trends of cultural values should not be mistaken for stereotyping.

Palliative care intervention in the intensive care unit: comparing outcomes among seriously ill Asian patients and those of other ethnicities

BACKGROUND

The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce.

AIM

The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU.

METHODS

A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care.

RESULTS

The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p = 0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p < 0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups.

CONCLUSION

Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU.

Myths of the High Medical Cost of Old Age and Dying

This report challenges commonly held beliefs about the financial and medical impact of older Americans during their last months of life. Written by physicians specializing in geriatrics, the report offers a wealth of data to refute seven misconceptions that currently influence U.S. health care policies: (1) that the growing number of older people has been the primary factor driving the rise in U.S. health care costs; (2) that as the population ages, health care costs for older Americans will necessarily overwhelm and bankrupt the nation; (3) that putting limits on health care for the very old at the end of life would save Medicare significant amounts of money; (4) that aggressive hospital care for the aged is futile and the money spent is wasted; (5) that it is common for older people to receive heroic, high-tech treatments at the end of life; (6) that Medicare covers everything that older adults need in terms of their health care; (7) that if older patients had living wills or other kinds of advance directives, it would resolve dilemmas of how aggressively to provide care.

There Is Hope for the Future: National Survey Results Reveal that Geriatric Medicine Fellows Are Well-Educated in End-of-Life Care

OBJECTIVES

To assess the status of geriatric medicine (GM) fellows' training experiences in end-of-life care via self-report.

DESIGN

Anonymous surveys completed by mail, Web access, and telephone.

SETTING

U.S. accredited GM fellowship training programs.

PARTICIPANTS

Two hundred ninety-six surveys were sent to graduating GM fellows in 1- and 2-year programs across the Unites States.

MEASUREMENTS

Measurements assessed self-reported attitudes, quantity and quality of end-of-life care education, preparation to provide care, and perceived value of caring for dying patients.

RESULTS

Response rate was 74%. Ninety-five percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. Seventy percent of fellows had completed a rotation focused on end-of-life care. Fellows who had done such rotations rated their end-of-life care education as highly as their overall geriatrics training. Fellows frequently received teaching in many end-of-life care topics, with lower rates of teaching how to say goodbye and responding to requests for assisted suicide. Overall, fellows felt well prepared to care for dying patients. Four factors independently predicted such preparedness: having had a palliative or end-of-life care rotation, being female, having been taught how to say goodbye to patients, and perceiving that it is important to attending physicians that fellows learn to care for dying patients.

CONCLUSION

GM fellows feel their end-of-life care education is excellent and feel prepared to take care of dying patients. It is critical that geriatricians in training have access to and take advantage of palliative and end-of-life care rotations.

Curricular Framework: Core Competencies in Multicultural Geriatric Care

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.

Palliative care module within a required geriatrics clerkship: taking advantage of existing partnerships

OBJECTIVE

LCME has recently required that all graduating medical students learn about end-of-life care. This program describes the design and integration into an existing geriatrics clerkship of a palliative care module that teaches the foundations of end-of-life and palliative care to medical students.

DESCRIPTION

Faculty experts in geriatrics met during a series of weekly meetings in 1999 to design a mandatory four-week-long clinical clerkship in geriatrics. Since the palliative care program is based within the geriatrics department, faculty members with interest and expertise in both geriatrics and palliative care were invited to design a palliative care module that can be integrated into the clerkship. Since LCME does not specify details of what students must learn about end-of-life care, and our goal is to educate and prepare students for any chosen specialty, we wanted to design a basic core curriculum in palliative care that would be useful to any graduating student. After reviewing potential palliative care topics, and given limited curriculum time, we condensed the medical student core curriculum to the following sessions: (1) Systematic Pain Assessment Management, (2) Management of Distressing Symptoms, (3) Communicating Bad News, and (4) Advance Directives. We developed PowerPoint presentations, teaching case vignettes, and a set of reference articles, which can be distributed to students as well as to help faculty teachers prepare for the sessions. Teaching sessions occur in small groups, using case discussions and interactive lectures. Sessions 3 and 4 are co-facilitated by palliative care physicians and ethicists, who use role-plays, reflections, and discussions to teach the topics. At the end of the clerkship, students practice these communication skills with videotaped standardized patient encounters, and debrief with faculty members about their performances and ways to improve their communication skills.

DISCUSSION

Palliative care sessions are welcomed by the students, who traditionally have not received much teaching in this area. Even though students have learned about mechanisms regulating pain and other symptoms in the past, they have not learned to assess or treat symptoms in a systematic way. Students often have good questions about the decision-making, legal, and ethical issues that emerge for patients near the end of life. Thus, co-facilitation of physicians with ethicists presents both the practical clinical and the theoretical perspectives, and provides a good model for team teaching. In terms of teaching style, students are more involved and participatory when teachers use case vignettes as compared with slide presentations, even if they are case-based. When using role-plays to teach students how to communicate bad news, we found that students need to feel safe in that environment, need to know they can call for time out when necessary, and want to have seen one done before they are asked to do one.

Complementary and alternative medicine (CAM) use by older adults: a comparison of self-report and physician chart documentation

BACKGROUND

Older adults are increasingly using complementary and alternative medicine (CAM) dietary supplements and herbal remedies, but may not discuss this with their physicians. When patients do report using CAM, their physicians may not record this information in patient charts.

METHODS

This cross-sectional analysis compared results of a convenience sample survey with medical charts. Participants were older than 65 and from an urban academic hospital's ambulatory geriatrics practice. We measured (i) prevalence of CAM use; (ii) proportion of CAM supplements and herbs (CAMsh) reported by patients and documented in patients' charts; (iii) percentage of patients reporting taking CAMsh with anticoagulant activity (ginger, ginkgo, garlic, and vitamin E) while concomitantly taking prescribed anticoagulant medications, as per chart; and (iv) percentages of those patients for whom the CAM anticoagulant was or was not documented in the chart.

RESULTS

We surveyed 212 patients; of those, 182 had available charts. Prevalence of CAM use was 64%. Only 35% of all self-reported supplements were documented in the charts. Of 182 patients, 84 (46%) reported taking CAM with anticoagulant properties: of these, 52% took a prescribed anticoagulant (per chart), while 48% took CAM but not prescribed anticoagulants.

CONCLUSION

CAM use is highly prevalent among older adults. Physicians do not consistently record the use of CAMsh on patients' charts. This may lead to unrecognized, potentially harmful drug-herb/drug-supplement interactions. Physicians should elicit and document information on CAM use from older adult patients, both to provide sound medical care and to advance knowledge about drug-herb/drug-supplement interactions.

How prevalent are hospital-based palliative care programs? Status report and future directions

In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.

Correlates of use of alternative medicine by the elderly in an urban population

OBJECTIVE

To investigate the prevalence and predictors of use of complementary and alternative medicine (CAM) by the elderly.

DESIGN

Cross-sectional survey examining patterns of use of complementary therapies in two urban multiethnic populations of older adults.

SETTING AND SUBJECTS

A convenience sample of 421 older participants were interviewed at two sites: a university geriatrics primary care practice and a veterans medical clinic, both in New York City. Subjects were excluded if they did not speak English or if they were moderately cognitively impaired.

MEASUREMENT

Use of CAM within the previous year.

RESULTS

Fifty-eight percent (58%) of all subjects surveyed used some form of CAM, and close to 75% at the university practice alone. Use correlated most strongly with female gender (p < 0.0001), greater education (p = 0.0095), thyroid disease (p = 0.0190) and arthritis (p = 0.0251). There was no correlation with income, race, age, or self-perceived health status.

CONCLUSIONS

CAM use is highly prevalent in older persons in this study, especially among females and those who are more highly educated.