Patient Portal Use Near the End-of-Life

Adverse impacts of natural disasters are viewed as particularly concerning for older adults. Disaster preparedness is an important step towards offsetting potential harm. Research comparing different age groups with respect to their disaster preparedness has produced inconclusive evidence. Some studies found older adults more prepared than younger age groups, whereas others found them to be equally or less prepared. To shed light on this issue, we examined disaster preparedness among N = 16,409 adults age 40 and older from the American Housing Survey. Using logistic regression analyses, we compared preparedness levels of four groups – households of middle-aged adults (age 40-64), older adults (age 65-84), oldest old adults (age 85+), and mixed households comprised of both middle-aged and older adults. Findings showed that households of older adults and the oldest old had significantly higher preparedness levels compared to middle-aged and mixed households, accounting for demographics, living alone, and disability. However, the oldest old group appeared less prepared compared to the older adult group. Thus, while our findings suggest that older adults aged 65-84 may be better prepared for disasters than middle-aged adults, the oldest old group, who are likely at a higher risk of adverse impacts from natural disasters, may be less prepared than their relatively younger counterparts. Therefore, older adults should not be treated as a homogenous group when considering disaster preparedness. Rather, policies and interventions to improve disaster preparedness may benefit from focusing on specific high vulnerability groups.

The patient-driven payment model: A missed opportunity for patient-centered cancer care

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.

Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review

Parkinson's disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life palliative care (hospice) than other illnesses, including other neurologic illnesses. Identification of predictors of PDRD mortality may aid in increasing appropriate and timely referrals. To systematically review the literature for causes of death and predictors of mortality in PDRD to provide guidance regarding hospice/end-of-life palliative care referrals. We searched MEDLINE, PubMed, EMBASE and CINAHL databases (1970-2020) of original quantitative research using patient-level, provider-level or caregiver-level data from medical records, administrative data or survey responses associated with mortality, prognosis or cause of death in PDRD. Findings were reviewed by an International Working Group on PD and Palliative Care supported by the Parkinson's Foundation. Of 1183 research articles, 42 studies met our inclusion criteria. We found four main domains of factors associated with mortality in PDRD: (1) demographic and clinical markers (age, sex, body mass index and comorbid illnesses), (2) motor dysfunction and global disability, (3) falls and infections and (4) non-motor symptoms. We provide suggestions for consideration of timing of hospice/end-of-life palliative care referrals. Several clinical features of advancing disease may be useful in triggering end-of-life palliative/hospice referral. Prognostic studies focused on identifying when people with PDRD are nearing their final months of life are limited. There is further need for research in this area as well as policies that support need-based palliative care for the duration of PDRD.

Development of a measure of decision quality for implantable defibrillators

BACKGROUND

CMS reimbursement guidelines for implantable cardioverter-defibrillators (ICDs) include mandated shared decision making (SDM), but without any manner of assessing the quality of decisions made. We developed and tested a scale meant to assess patients' knowledge of and preferences specific to ICDs. Such a tool would assess these constructs in the clinical environment, targeting resources and support for patients considering a primary prevention ICD.

METHODS

Development of the ICD decision quality (ICD-DQ) scale included (1) item creation, (2) content validation using surveys of patients (n = 23) and clinicians (n = 31), and (3) examination of validity and reliability using a survey of patients who previously received an ICD (n = 295, response rate = 72%).

RESULTS

The final scale consists of 12 knowledge and 8 preference items. With respect to content validity, clinician and patient respondents agreed on the importance of 19 of 24 candidate knowledge items (79%), and 9 of 11 treatment preference items (81%). Knowledge items exhibited moderate internal validity (α = 0.62, 1 factor), strong test-retest reliability (mean % correct at first administration = 59%, 62% at follow-up, P > .1) and discriminant validity (59% correct for patients, 93% among cardiologists). Short versions of the ICD-DQ were developed for clinical settings, the scores from both of which correlated with the long version in this cohort (11-item (r = 0.90) and a 5-item (r = 0.75)).

CONCLUSIONS

The ICD-DQ fills a critical gap in measuring the quality of patients' ICD decisions. They may be used to evaluate the effectiveness of patient decision aids or the quality of SDM in clinical practice.

Development of a Web-Based Intervention for Addressing Distress in Caregivers of Patients Receiving Stem Cell Transplants: Formative Evaluation With Qualitative Interviews and Focus Groups

Background

Caregivers of cancer patients experience significant burden and distress including depression and anxiety. We previously demonstrated the efficacy of an eight session, in-person, one-on-one stress management intervention to reduce distress in caregivers of patients receiving allogeneic hematopoietic stem cell transplants (allo-HSCT).

Objective

The objective of this study was to adapt and enhance the in-person caregiver stress management intervention to a mobilized website (eg, tablet, smartphone, or computer-based) for self-delivery in order to enhance dissemination to caregiver populations most in need.

Methods

We used an established approach for development of a mhealth intervention, completing the first two research and evaluation steps: Step One: Formative Research (eg, expert and stakeholder review from patients, caregivers, and palliative care experts) and Step Two: Pretesting (eg, Focus Groups and Individual Interviews with caregivers of patients with autologous HSCT (auto-HSCT). Step one included feedback elicited for a mock-up version of Pep-Pal session one from caregiver, patients and clinician stakeholders from a multidisciplinary palliative care team (N=9 caregivers and patient stakeholders and N=20 palliative care experts). Step two included two focus groups (N=6 caregivers) and individual interviews (N=9 caregivers) regarding Pep-Pal’s look and feel, content, acceptability, and potential usability/feasibility. Focus groups and individual interviews were audio-recorded. In addition, individual interviews were transcribed, and applied thematic analysis was conducted in order to gain an in-depth understanding to inform the development and refinement of the mobilized caregiver stress management intervention, Pep-Pal (PsychoEducation and skills for Patient caregivers).

Results

Overall, results were favorable. Pep-Pal was deemed acceptable for caregivers of patients receiving an auto-HSCT. The refined Pep-Pal program consisted of 9 sessions (Introduction to Stress, Stress and the Mind Body Connection, How Thoughts Can Lead to Stress, Coping with Stress, Strategies for Maintaining Energy and Stamina, Coping with Uncertainty, Managing Changing Relationships and Communicating Needs, Getting the Support You Need, and Improving Intimacy) delivered via video instruction through a mobilized website.

Conclusions

Feedback from stakeholder groups, focus groups, and individual interviews provided valuable feedback in key areas that was integrated into the development of Pep-Pal with the goal of enhancing dissemination, engagement, acceptability, and usability.

Palliative Care and Parkinson's Disease: Caregiver Perspectives

BACKGROUND

Palliative care for Parkinson's disease (PD) is an emerging area of interest for clinicians, patients and families. Identifying the palliative care needs of caregivers is central to developing and implementing palliative services for families affected by PD. The objective of this paper was to elicit PD caregiver needs, salient concerns, and preferences for care using a palliative care framework.

MATERIALS AND METHODS

11 PD caregivers and one non-overlapping focus group (n = 4) recruited from an academic medical center and community support groups participated in qualitative semi-structured interviews. Interviews and focus group discussion were digitally recorded, transcribed and entered into ATLAS.ti for coding and analysis. We used inductive qualitative data analysis techniques to interpret responses.

RESULTS

Caregivers desired access to emotional support and education regarding the course of PD, how to handle emergent situations (e.g. falls and psychosis) and medications. Participants discussed the immediate impact of motor and non-motor symptoms as well as concerns about the future, including: finances, living situation, and caretaking challenges in advanced disease. Caregivers commented on the impact of PD on their social life and communication issues between themselves and patient. All participants expressed interest and openness to multidisciplinary approaches for addressing these needs.

CONCLUSIONS

Caregivers of PD patients have considerable needs that may be met through a palliative care approach. Caregivers were receptive to the idea of multidisciplinary care in order to meet these needs. Future research efforts are needed to develop and test the clinical and cost effectiveness of palliative services for PD caregivers.

Designing Effective Interactions for Concordance around End-of-Life Care Decisions: Lessons from Hospice Admission Nurses

Near the end of life, hospice care reduces symptom-related distress and hospitalizations while improving caregiving outcomes. However, it takes time for a person to gain a sufficient understanding of hospice and decide to enroll. This decision is influenced by knowledge of hospice and its services, emotion and fear, cultural and religious beliefs, and an individual’s acceptance of diagnosis. Hospice admission interactions, a key influence in shaping decisions regarding hospice care, happen particularly late in the illness trajectory and are often complex, unpredictable, and highly variable. One goal of these interactions is ensuring patients and families have accurate and clear information about hospice care to facilitate informed decisions. So inconsistent are practices across hospices in consenting patients that a 2016 report from the Office of Inspector General (OIG) entitled “Hospices should improve their election statements and certifications of terminal illness” called for complete and accurate election statements to ensure that hospice patients and their caregivers can make informed decisions and understand the costs and benefits of choosing hospice care. Whether complete and accurate information at initial admission visits improves interactions and outcomes is unknown. Our recent qualitative work investigating interactions between patients, caregivers, and hospice nurses has uncovered diverse and often diverging stakeholder-specific expectations and perceptions which if not addressed can create discordance and inhibit decision-making. This paper focuses on better understanding the communication dynamics and practices involved in hospice admission interactions in order to design more effective interactions and support the mandate from the OIG to provide hospice patients and their caregivers with accurate and complete information. This clarity is particularly important when discussing the non-curative nature of hospice care, and the choice patients make to forego aggressive treatment measures when they enroll in hospice. In a literal sense, to enroll in hospice means to bring in support for end-of-life care. It means to identify the need for expertise around symptom management at end-of-life, and agree to having a care team come and manage someone’s physical, psychosocial, and/or spiritual needs. As with all care, hospice can be stopped if it is no longer considered appropriate. To uncover the communication tensions undergirding a hospice admission interaction, we use Street’s ecological theory of patient-centered communication to analyze a case exemplar of a hospice admission interaction. This analysis reveals diverse points of struggle within hospice decision-making processes around hospice care and the need for communication techniques that promote trust and acceptance of end-of-life care. Lessons learned from talking about hospice care can inform other quality initiatives around communication and informed decision-making in the context of advance care planning, palliative care, and end-of-life care.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

Parkinson disease patients' perspectives on palliative care needs: What are they telling us?

BACKGROUND

A growing body of literature suggests that patients with Parkinson disease (PD) have many unmet needs under current models of care that may be addressed through palliative care approaches. A first step in improving care for patients with PD through palliative care principles is to better understand patient perspectives on their perceived needs and care preferences.

METHODS

A total of 30 in-depth individual interviews and 4 focus groups were held to elicit the perspectives of patients with PD on unmet palliative care needs and preferences for addressing these needs. We used ATLAS.ti and inductive qualitative data analysis techniques to interpret responses.

RESULTS

Patients articulated major challenges in living with a diverse and complex set of motor and nonmotor symptoms; feelings of loss; changes in roles, relationships, and concept of self; and expressed concerns about the future. Participants discussed gaps in their care, including support at the time of diagnosis, education about the disease, and advance care planning. There was an expressed interest in and openness of participants to interdisciplinary approaches for addressing these needs.

CONCLUSIONS

PD has a profound effect on multiple domains of a person's life starting at diagnosis. Patients desired individualized care and identified several areas where care from their primary neurologist could be improved. Patients were receptive to outpatient team-based palliative care services to address psychosocial issues, adjustment to illness (particularly at diagnosis and with progression), nonmotor symptom control, and advance care planning as an adjunct to usual care. Future research is needed to develop and test the effectiveness of palliative approaches to improve the care of patients with PD.

Palliative care research skill development needs: Lessons from the Palliative Care Research Cooperative Group (PCRC)

174

Background: The field of palliative care (PC) has grown substantially over the past decade. PC research has not kept pace, however. One contributing factor is the paucity of clinical investigators equipped to conduct rigorous PC studies, especially multisite studies focused on interventions, dissemination and implementation. A core mission of the Palliative Care Research Cooperative (PCRC) is to enhance investigator capacity to conduct applied patient/caregiver-centered research. Methods: The PCRC Investigator Development Center (IDC) performed two needs assessments in 2015: 1) PCRC methodologic Core Directors; and 2) a subset of PCRC junior investigators. Results: Through these two assessments, PCRC identified the following knowledge/skills gaps in planning and implementing multisite clinical trials and implementation research: basic principles of clinical trials, nuts and bolts of multisite clinical trials, special considerations in behavioral and pragmatic clinical trials, testing treatment efficacy vs testing treatment effectiveness, selection of endpoints and measurement tools, recruitment and adherence issues unique to palliative care populations, data safety monitoring, budgeting and development of protocols/training for multi-site trials. These knowledge/skills gaps were identified by junior investigators as well as by senior investigators whose prior experience is primarily with single-site studies or secondary data analyses. Conclusions: Advancement of PC research requires upskilling of investigators n conduct of multisite studies. The PCRC is partnering with the National Palliative Care Research Center (NPCRC) to make available a range of investigator development resources, including one-on-one mentoring, grant review support, webinars and palliative care research boot camps.

Discontinuing chronic medications: Perceptions of patients with life-limiting illness

97

Background: Optimal management of chronic medications is uncertain in life-limiting illness. To inform shared decision making, we assessed patient perceptions in a trial on the safety of discontinuing statins in life-limiting illness. Methods: Eligible adults (life expectancy 1–12 months, on statin for ≥ 3 months for primary/secondary prevention, recent functional decline, no active cardiovascular disease) were randomized to discontinue or continue statins and were followed monthly for up to 1 year. Cognitively intact participants were asked 9 questions regarding discontinuing statins prior to randomization. We used Pearson chi-square to compare responses between study groups and between those with and without cancer. Of 381 participants, 297 (78%) were cognitively intact (138 discontinued, 159 continued statins). Mean age was 72 years (SD 11) and mean number of medications used was 11.5 (SD 5.0); 58% (N = 173) had cancer. Results: There were no statistically significant differences between the study groups in responses to the medication perception questions. Aggregate findings are presented (Table). Patients with cancer were less likely to think that they may be able to stop other medications (28% vs. 42%, p=0.007) and that statin discontinuation means that the doctor is giving up on them (1% vs. 7%, p=0.013). Conclusions: Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cancer patients may perceive less impact from stopping statins. Clinicians should inquire about patient concerns when engaging in shared decision making about discontinuing chronic medications in the setting of advanced cancer. Clinical trial information: NCT01415934. [Table: see text]

Trajectories of performance status decline in advanced cancer

100

Background: Historically, functional decline is considered to occur steadily and inexorably in the last months of life, with a relatively steep trajectory compared to non-cancer patients (pts). As part of a trial evaluating the safety and clinical impact of discontinuing statin medications for patients in the palliative care setting, we recorded the performance status (PS) in 186 cancer patients regularly during their time on study and compared changes among those with differing baseline PS levels and between those with and without cancer. Methods: This was a multi-center, parallel-group, unblinded pragmatic trial. Eligibility included: age > 18; life expectancy between 1 month and 1 year, on a statin for ≥ 3 months for primary or secondary prevention, recent deterioration in PS and no recent active cardiovascular disease. Participants, randomized to either discontinue or continue statins, were followed monthly for up to 1 year. Outcomes included survival, cardiovascular events, and PS. PS was measured using the Australia-modified Karnofsky Performance Status (AKPS) scale and grouped into 4 categories: AKPS=70, 60; 50 and 0-40. The trajectory of PS decline for each group was modeled using a piecewise-linear function allowing for knots at 4, 8, and 12 weeks and separated out between those participants who died and did not die during their time on study. A mixed model was used allowing for a random intercept for each participant. Results: Among the 186 subjects whose primary diagnosis was cancer, 111 died; among 195 without cancer, 75 died. Those who did not die maintained a relatively flat trajectory of AKPS across 20 weeks; for those who did die, AKPS scores declined somewhat over 20 weeks but this decline was most remarkable among those with a starting AKPS of 0-40. Compared to noncancer patients who died during the study period, PS levels were higher at baseline and had initially greater rates of decline. Conclusions: For advanced cancer patients, PS declines are less dramatic than previous estimates have suggested except for those with AKPS 0-40, suggesting precipitous declines at the very end of life for those with higher initial AKPS. Compared to noncancer patients, PS decline is slightly steeper among cancer pts.

A prospective assessment of polypharmacy in the palliative care setting

112

Background: The number of prescribed medications increases substantially in the last year of life aggravating the risk of polypharmacy, adverse reactions and medication non-adherence. What medications do patients with life-limiting illness take? Methods: This was a pre-specified secondary analysis of data from a prospective trial. Eligible participants were adults with a <1-year prognosis taking a statin medication for primary or secondary prevention. Participants were enrolled from 15 sites, randomized to continue or discontinue statin medications, and followed for up to a year. Concomitant medications were recorded at least monthly. For participants with a primary diagnosis of cancer receiving care and with medication data available, prescribed medications were categorized according to the World Health Organization’s (WHO) ‘Guidelines for ATC Classification’ by class and sub-class. An expert panel of palliative care, oncology, geriatrics, and primary care physicians guided categorization. Descriptive statistics were calculated. Results: On average, participants (N=127) were 70 years old (SD 10) and lived 216 days (SD 123) on study; 69% had metastases, 23% had cancer without metastases, 7% had lymphoma, and 1 had leukemia. In total, 49 classes, 156 sub-classes and 283 different medications were prescribed. The five most commonly prescribed medications were: anti-hypertensives, strong opioids, laxatives, gastric protection aids, and anti-emetics. Only 1.2% of medications prescribed were chemotherapy or antineoplastics. Patients took an average of 10.7 (SD 5) number of medications at the time of enrollment and 10.0 (SD 5) medications at death or termination of the study. 31% of patients were on 15 or more medications at any time during the study. Conclusions: Polypharmacy, defined as >10 medicines, is common in the last year of life for people with cancer. Patients commonly receive supportive care medications and drugs for comorbidities like hypertension; antineoplastics are rare. Thoughtful approaches to medication simplification in the palliative care setting are needed.

Palliative care and neurology: time for a paradigm shift

Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research.

Managing comorbidities in oncology: A multisite randomized controlled trial of continuing versus discontinuing statins in the setting of life-limiting illness

LBA9514

Background: For patients with life-threatening illness such as advanced cancer, optimal management of longstanding medications prescribed for comorbid illness is uncertain. Risks may outweigh benefits; e.g., benefits from HMG Co-A reductase inhibitors (“statins”) may take years to accrue and may not be relevant for a person with limited prognosis. Is it safe to discontinue statins for the patient with less than a year to live? Methods: This was a multicenter, unblinded pragmatic trial. At enrollment, participants were randomized (1:1) to discontinue or continue their statin medication. Eligible patients were adults with advanced life-limiting illness on a statin for ≥3 months for primary or secondary prevention, a life expectancy of greater than one month, and evidence of recent deterioration in performance status. Outcomes measured at baseline and at least monthly included survival, cardiovascular-related events, quality of life (QOL), symptoms, and polypharmacy. Rate of death within 60 days of randomization was the primary outcome. Results: 381 patients were enrolled (189 discontinue statins; 192 continue statins). Mean age was 74 years (SD 12); 22% were cognitively impaired; 49% had cancer as the primary diagnosis; and, 69% had used statins for >5 years. Rate of death within 60 days was not statistically different between groups (discontinue vs. continue, 23.8% vs. 20.3%, 90% CI -3.5% to 10.5%, p=0.36). The group discontinuing statins had longer median time-to-death (229 days [90% CI 186–332] vs. 190 days [90% CI 170-257]; p=0.60). Total QOL was significantly better among the group discontinuing statins (McGill QOL: 7.11 vs. 6.85, p=0.037) and there were fewer symptoms in this group (Edmonton Symptom Assessment Scale: 25.2 vs. 27.4, p=0.128). People in the discontinue statins group took significantly fewer medications (10.1 vs. 10.8, p = 0.034). Few participants in either group experienced cardiovascular events (13 vs. 11). Conclusions: In the setting of life-limiting illness such as advanced cancer, it is unlikely that harm will accrue when statins being used for primary or secondary prevention are discontinued; these patients may even benefit. Clinical trial information: NCT01415934.

Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults

BACKGROUND

Death in the U.S. frequently occurs in institutions despite the overwhelming majority of persons who state that they prefer to die at home. Little research to date has examined how well individual preferences compare to actual site of death.

OBJECTIVES

Determine the concordance between preferred and actual place of death and examine independent predictors for concordance.

DESIGN

Observational cohort study.

SETTING

Three area hospitals including a safety net hospital, veterans' hospital, and academic tertiary referral center.

PATIENTS

458 adult patients admitted to the general medical service from 2003-2005.

MEASUREMENTS

Patients were asked where they preferred to spend their last days of life. Data on date and actual site of death from 2005-2009 was collected from hospital records and death certificates.

RESULTS

The majority of patients preferred to die at home (75% n = 343). Low income and being married were significantly associated with a preference to die at home compared to nursing home or inpatient hospice (OR 2.71 95% CI 1.30-5.67 and OR 2.44 95% CI 1.14-5.21 respectively). Of the 123 patients who died during the follow up period, most (66% n = 80) died in an institutional setting. Overall concordance between preferred and actual site of death was only 37% (n = 41). Female gender was significantly associated with concordance between preferred and actual site of death (OR 3.30 95% CI 1.25-8.72).

CONCLUSIONS

Concordance between preferred and actual site of death is low and female gender was the sole patient level variable associated with concordance.

The FACIT-AI, a new tool for assessing symptoms associated with malignant ascites

OBJECTIVE

The objectives of this study are to assess the clinical relevance and validity of the Functional Assessment of Chronic Illness Therapy-Ascites Index (FACIT-AI) in women with ovarian cancer and malignant ascites, and to modify the instrument guided by qualitative feedback from patients with recurrent malignant ascites.

METHODS

Fourteen adult female patients with recurrent symptomatic malignant ascites were enrolled from three centers. All completed an open-ended symptom list to identify their primary concerns regarding their condition. They then completed a draft 10-item FACIT-AI questionnaire created from expert input. Eleven patients provided comments regarding the FACIT-AI questionnaire using a written feedback format. Three patients participated in a "think-aloud" cognitive debriefing interview to ensure patient comprehension of questionnaire items.

RESULTS

Of the first 11 patients surveyed, 7 believed that the draft FACIT-AI contained all important symptoms associated with malignant ascites. Responses from the remaining 4 patients revealed three symptoms that 2 or more patients nominated for inclusion: urinary frequency, constipation and emotional distress. These items were added to the original FACIT-AI to produce a 13-item index of symptoms associated with malignant ascites.

CONCLUSIONS

The 13-item FACIT-AI has content validity among women with malignant ascites associated with ovarian cancer. It is available for use in clinical research or practice, with the expectation that more will be learned about its performance and interpretation over time.

Advance directive discussions: lost in translation or lost opportunities?

BACKGROUND

Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness.

METHODS

This was a prospective observational cohort study of 458 adults admitted to the general medical services of a safety net hospital, an academic medical center, and a Veterans' Affairs (VA) hospital. Patients were asked if they had discussed advance directives, and we reviewed medical records for documented advance directives.

RESULTS

Overall, 45% of patients reported having had a discussion about advance directives (29% of Latinos compared with 54% of Caucasians, p=0.0002) and 24% of patients had a completed advance directive in their medical record (25% Latinos and 26% of Caucasians, p=not significant [ns]). Using logistic regression modeling and adjusting for socioeconomic status (SES), education level, and language spoken, Latinos (odds ratio [OR] 0.42, confidence interval [CI] 0.24-0.75) were less likely to report having advance directive discussions compared with Caucasians (referent). However, modeling of a completed advance directive in the medical record showed no significant difference between Latinos (OR 1.44, CI 0.73-2.85) and Caucasians (referent).

CONCLUSIONS

The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.

"From the prison door right to the sidewalk, everything went downhill," a qualitative study of the health experiences of recently released inmates

In many states, budget constraints are prompting earlier release of prison inmates. Prior studies have demonstrated elevated mortality rates in the post-release period but little is known about the health experiences of former inmates in the transition from prison to the community. The objective of this study was to understand the health-seeking experiences, perceptions of risk, and medical and mental health needs of former prisoners in the first two months after release from prison. Participants consisted of 29 former inmates within the first two months after their release from prison to the Denver, Colorado area. Using qualitative methods, trained interviewers conducted individual, in-person, semi-structured interviews exploring participants' experiences with health, mental health, and health care since release. Interview transcripts were coded and analyzed utilizing a team-based approach to inductive analysis. We found that health-related behavior occurred in the context of a complex life experience, with logistical problems exacerbated by emotional distress. Major themes included 1) transitional challenges; 2) cognitive responses including perceptions about personal risk, knowledge and priorities; 3) emotional responses including pronounced stress, fear, anxiety, disappointment; and 4) health behaviors. Former inmates reported multiple challenges, poor transitional preparation preceding release, and inadequate or absent continuity of mental and physical health care in the context of significant emotional distress and anxiety. Improved release planning, coordination between the medical, mental health and criminal justice systems may reduce the risk of poor health outcomes for this population.

Methodological challenges in conducting a multi-site randomized clinical trial of massage therapy in hospice

Researchers conducting multi-site studies of interventions for end-of-life symptom management face significant challenges with respect to obtaining an adequate sample and training and retaining on-site study teams. The purpose of this paper is to describe the strategies and responses to these challenges in a multi-site randomized clinical trial (RCT) of the efficacy of massage therapy for decreasing pain among patients with advanced cancer in palliative care/hospice settings. Over a period of 36 months, we enrolled 380 participants across 15 sites; 27% of whom withdrew prior to study completion (less than the anticipated 30% rate). We saw an average of 68% turnover amongst study staff. Three key qualities characterized successful on-site study teams: (1) organizational commitment; (2) strong leadership from on-site study coordinators; and (3) effective lines of communication between the on-site study coordinators and both their teams and the university-based research team. Issues of recruitment, retention and training should be accounted for in hospice-based research study design and budgeting.

Variation in pain medication use in end-of-life care

BACKGROUND

Pain is a common and distressing symptom at the end of life that medications can help relieve. We sought to explore variation in approaches to pharmaceutical management of pain among hospice-eligible patients and to determine if variation was explained by patient or site of care characteristics. Variation in medication use may suggest areas for best practices or quality improvement in medication use in end-of-life care.

METHODS

We conducted a secondary analysis of randomized trial data, examining use of five medication classes: opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant pain medications (tricyclics and antiseizure), stimulants, and antianxiety medications in 16 study sites nationwide. Descriptive statistics were generated for patient-level data and by site. Unadjusted and adjusted odds ratios were calculated to compare patient and location of care characteristics with each medication class use by site.

RESULTS

We found variation in medication use was not predicted by most patient characteristics or location of care (home versus facility). Use of all types of pain medications decreased with age (odds ratio [OR] 0.75 [0.63-0.90]). Medication use varied between sites: a range of 14%-83% of patients were on different types of opiates, 0%-40% on NSAIDS, 20%-69% on benzodiazepines, 0%-25% on adjuvant medications, and 0%-23% were on acetaminophen at any time during the data collection period.

CONCLUSIONS

Pain and adjuvant medication use differs widely by site of care. Further research is needed to determine the extent to which provider and patient choice contribute to prescribing variation, and to explore associations between patient symptoms, medication variation, and patient care quality.

Support needs of informal hospice caregivers: a qualitative study

BACKGROUND

Informal caregivers of hospice patients experience multiple stressors that can negatively impact physical, psychological, and emotional health. The goal of this qualitative study was to understand caregivers' needs to inform the feasibility, structure, and content of a telephone-based counseling intervention.

METHODS

Focus groups and interviews with 36 former hospice caregivers and 11 hospice staff from 6 hospices were conducted. Interviews and focus groups were audio-recorded, transcribed, and analyzed using a constant comparative approach.

RESULTS

Key content areas included coping, emotional support, self-care, logistical issues, and bereavement. Respondents supported telephone-based counseling, appreciating its relative anonymity and convenience. It was recommended that calls be initiated by the counselor, on a weekly basis, and that one counselor be assigned to each caregiver. Hospice staff emphasized the need to coordinate telephone counseling with hospice care, scheduling around and communicating with hospice staff. Most caregivers indicated that they would participate in telephone-based counseling were it available; hospice staff thought that half of caregivers would participate. A pervasive theme was that "there can never be enough support for a caregiver."

CONCLUSION

Informal caregivers of hospice patients have support needs that are amenable to telephone-based counseling designed to be complementary to existing hospice services. Based on these qualitative findings, we are pilot-testing a telephone-based cognitive-behavioral stress management program for informal caregivers of hospice patients.

Lack of patient knowledge regarding hospital medications

BACKGROUND

Patient involvement in preventing inpatient medication errors is predicated upon patient knowledge of their medications. However, there is little published on the accuracy of patient knowledge or understanding of their hospital medications.

OBJECTIVE

To assess hospitalized patients' knowledge of their hospital medications and attitudes towards involvement in the medication safety process while hospitalized.

METHODS

A cross-sectional study of 50 adult internal medicine inpatients at the University of Colorado Hospital. Patients completed a list of the hospital medications they believed were prescribed to them and a survey of attitudes toward involvement in the medication safety process. The patient-completed hospital medication list was compared to the hospital medication administration record.

RESULTS

Ninety-six percent of study patients omitted at least one prescribed hospital medication. On average, patients omitted 6.8 hospital medications. Forty-four percent of patients believed they were receiving at least one hospital medication that was not actually prescribed. Patients < 65 years old omitted 60% of their as needed (PRN) medications whereas patients > or = 65 years old omitted 88% (P = 0.01). Only 28% reported having seen their hospital medication list, although 81% reported this would improve their satisfaction with hospital care. Ninety percent wanted to review their hospital medication list for accuracy and 94% felt patient review of the hospital medication list had the potential to reduce errors.

CONCLUSIONS

Our findings suggest that, in contrast to patient preferences, there are significant deficits in patients' knowledge of hospital medications. These results are a call to reexamine how we educate patients regarding their hospital medications.

Part-time careers in academic internal medicine: a report from the association of specialty professors part-time careers task force on behalf of the alliance for academic internal medicine

To establish guidelines for more effectively incorporating part-time faculty into departments of internal medicine, a task force was convened in early 2007 by the Association of Specialty Professors. The task force used informal surveys, current literature, and consensus building among members of the Alliance for Academic Internal Medicine to produce a consensus statement and a series of recommendations. The task force agreed that part-time faculty could enrich a department of medicine, enhance workforce flexibility, and provide high-quality research, patient care, and education in a cost-effective manner. The task force provided a series of detailed steps for operationalizing part-time practice; to do so, key issues were addressed, such as fixed costs, malpractice insurance, space, cross-coverage, mentoring, career development, productivity targets, and flexible scheduling. Recommendations included (1) increasing respect for work-family balance, (2) allowing flexible time as well as part-time employment, (3) directly addressing negative perceptions about part-time faculty, (4) developing policies to allow flexibility in academic advancement, (5) considering part-time faculty as candidates for leadership positions, (6) encouraging granting agencies, including the National Institutes of Health and Veterans Administration, to consider part-time faculty as eligible for research career development awards, and (7) supporting future research in "best practices" for incorporating part-time faculty into academic departments of medicine.

Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient

The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients' cognitive limitations. Evidence suggests deficits in communication by hospital physicians to primary care providers occur commonly but this is only one of many systems barriers to successful discharge. Review of the literature reveals interventions such as involvement of advance practice nurses or family members in the transition may overcome some of the difficulties inherent in discharge of the vulnerable geriatric patient. Weekend discharges present unique challenges and potential solutions are explored. This case offers the opportunity to review the elements necessary for success and insight into the systems limitations which underlie failed transitions.

Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs

Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training.

Implementing palliative care studies

This session focused on issues related to implementation of randomized clinical trials in palliative care studies. Topics discussed included what kinds of clinical sites and patient populations were suitable, what types of clinical investigators (clinical specialty) should be involved in or lead the studies, what multisite mechanisms could be used to conduct the trials, and what funding issues were related to these studies. A trial of operative versus nonoperative management for small bowel obstruction caused by recurrent intra-abdominal cancer was considered. The feasibility of such a trial was examined in terms of whether there was "equipoise" for a majority of likely investigators in the field around the trial question, what other issues might impact accrual to the trial, and how many patients would be required to answer which of these two treatment arms was better. This last question is related to selection of a primary endpoint for the trial and was a modestly contentious issue for the trial design group. Both sensible compromises in endpoint selection and the education of the community of investigators for a particular randomized trial in palliative care are crucial steps for successful implementation. A major conclusion of this session is that implementation considerations are intimately related to the architecture of a specific trial and should be addressed practically and early in the design phase of any randomized trial addressing a palliative care question. In this respect, randomized trials in palliative care are no different than in other fields.

Consensus statement: Palliative and supportive care in advanced heart failure

BACKGROUND

A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure."

EVIDENCE

Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews.

CONCLUSIONS

The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.

Alternative/complementary medicine: wider usage than generally appreciated

OBJECTIVE

To test the hypothesis that there is substantial use of a practitioner of alternative/complementary medicine by patients traditionally considered to be underserved.

DESIGN

Cross-sectional, self-administered survey study.

SETTINGS

Three university hospital-affiliated general ambulatory clinics serving patients of different socioeconomic status and racial origin.

SUBJECTS

Five hundred and thirty-six (93% of those attending) consecutive clinic attendees.

OUTCOME MEASURES

Past use and desired future use of one or more practitioners of five modalities of alternative/complementary medicine and willingness to pay for these modalities out-of-pocket.

RESULTS

Past usage and desired future usage of one or more practitioners of alternative/complementary medicine was comparable at the three clinic sites despite wide differences in socioeconomic status and willingness/ability to pay out-of-pocket for these services. Multivariable analyses revealed lower self-rated health status and female gender (both p < 0.006) but not income, race, age or education as independent, significant predictors of use of a practitioner of alternative/complementary medicine.

CONCLUSION

Usage of alternative/complementary medicine is not confined to any well-circumscribed socioeconomic group and is common in patients often considered to be underserved. Self-assessed lower health status is significantly and independently associated with use of a practitioner of alternative/complementary care.

Recognition of patient referral desires in an academic managed care plan frequency, determinants, and outcomes

OBJECTIVE

To determine the frequency and determinants of provider nonrecognition of patients' desires for specialist referral.

DESIGN

Prospective study.

SETTING

Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan.

PARTICIPANTS

Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits.

MEASUREMENTS AND MAIN RESULTS

Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients' referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P <.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P <.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered "not indicated" by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred.

CONCLUSIONS

These PCPs frequently failed to explicitly recognize patients' referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire.

Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated.