Challenges in communication, prognostication and dialysis decision-making in the COVID-19 pandemic: implications for interdisciplinary care during crisis settings.

PURPOSE OF REVIEW: Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. RECENT FINDINGS: Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. SUMMARY: The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings.

Anxiety, depression, and end-of-life care utilization in adults with metastatic cancer.

OBJECTIVE: End-of-life care for patients with cancer is often overly burdensome, and palliative and hospice care are underutilized. The objective of this study was to evaluate whether the mental health diagnoses of anxiety and depression were associated with variation in end-of-life care in metastatic cancer. METHODS: This study used electronic health data from 1,333 adults with metastatic cancer who received care at two academic health centers in Louisiana, USA, and died between 1/1/2011-12/31/2017. The study used descriptive statistics to characterize the sample and logistic regression to examine whether anxiety and depression diagnoses in the six months before death were associated with utilization outcomes (chemotherapy, intensive care unit [ICU] visits, emergency department visits, mechanical ventilation, inpatient hospitalization, palliative care encounters, and hospice utilization), while controlling for key demographic and health covariates. RESULTS: Patients (56.1% male; 65.6% White, 31.1% Black) commonly experienced depression (23.9%) and anxiety (27.2%) disorders within six months of death. Anxiety was associated with an increased likelihood of chemotherapy (odds ratio [OR] = 1.42, p = 0.016), ICU visits (OR = 1.40, p = 0.013), and inpatient hospitalizations (OR = 1.85, p < 0.001) in the 30 days before death. Anxiety (OR = 1.95, p < 0.001) and depression (OR = 1.34, p = 0.038) were associated with a greater likelihood of a palliative encounter. CONCLUSIONS: Patients with metastatic cancer who had an anxiety disorder were more likely to have burdensome end-of-life care, including chemotherapy, ICU visits, and inpatient hospitalizations in the 30 days before death. Depression and anxiety both increased the odds of palliative encounters. These results emphasize the importance of mental health considerations in end-of-life care.

Advance Care Planning Practice Patterns Before and During a Pandemic.

Introduction: The COVID-19 pandemic resulted in introspection of the United States health care infrastructure, especially with advance care planning (ACP). Methods: This is a retrospective chart review assessing the frequency of ACP discussions and formal documents reflecting ACP wishes in an outpatient palliative medicine (PM) practice. The study site was at University Medical Center New Orleans from pre-COVID-19 surge (November 2019-February 2020) to months during and post-COVID-19 surge (March-April 2020). Results: Results showed an increase in ACP discussions during the post-COVID-19 months. Patients seen during the surge and post-COVID-19 months were more likely to discuss medical power of attorney (odds ratio [OR] = 1.78, p = 0.045) and preferred code status (OR = 2.82, p < 0.001). Conclusion: Our study showed that more ACP discussions were conducted post-COVID-19 versus pre-COVID-19. However, formal documents reflecting these wishes were lacking. These results can help guide ACP use in crisis periods and improve understanding of ACP discussions in an outpatient PM clinic.

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain.

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention.

CONTEXT: Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care. OBJECTIVES: To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy. METHODS: The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes. RESULTS: Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001). CONCLUSIONS: This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.

Prognostication and Proactive Planning in COVID-19.

Accurate prognostication is challenging in the setting of SARS-CoV-2, the virus responsible for COVID-19, due to rapidly changing data, studies that are not generalizable, and lack of morbidity and functional outcomes in survivors. To provide meaningful guidance to patients, existing mortality data must be considered and appropriately applied. Although most people infected with SARS-CoV-2 will recover, mortality increases with age and comorbidity in those who develop severe illness.

Development and Validation of the Palliative Care Attitudes Scale (PCAS-9): A Measure of Patient Attitudes Toward Palliative Care.

CONTEXT: Palliative Care is underutilized, and research has neglected patient-level factors including attitudes that could contribute to avoidance or acceptance of Palliative Care referrals. This may be due in part to a lack of existing measures for this purpose. OBJECTIVES: The objective of this study was to develop and validate a nine-item scale measuring patient attitudes toward Palliative Care, comprised of three subscales spanning emotional, cognitive, and behavioral factors. METHODS: Data were collected online in three separate waves, targeting individuals with cancer (Sample 1: N = 633; Sample 2: N = 462) or noncancer serious illnesses (Sample 3: N = 225). Participants were recruited using ResearchMatch.org and postings on the web sites, social media pages, and listservs of international health organizations. RESULTS: Internal consistency was acceptable for the total scale (α = 0.84) and subscales: emotional (α = 0.84), cognitive (αs = 0.70), and behavioral (α = 0.90). The PCAS-9 was significantly associated with a separate measure of Palliative Care attitudes (ps < 0.001) and a measure of Palliative Care knowledge (ps < 0.004), supporting its construct validity in samples of cancer and noncancer serious illnesses. The scale's psychometric properties, including internal consistency and factor structure, generalized across patient subgroups based on diagnosis, other health characteristics, and demographics. CONCLUSION: Findings support the overall reliability, validity, and generalizability of the PCAS-9 in serious illness samples and have implications for increasing Palliative Care utilization via clinical care and future research efforts.

The Development of Pathways in Palliative Medicine: Definition, Models, Cost and Quality Impact.

Palliative Care and its medical subspecialty, known as Palliative Medicine, is the care of anyone with a serious illness. This emerging field includes Hospice and comfort care, however, it is not limited to end-of-life care. Examples of the types of serious illness that Palliative Medicine clinicians care for include and are not limited to hematologic and oncologic diseases, such as cancer, advanced heart and lung diseases (e.g., congestive heart failure and chronic obstructive pulmonary disorder), advanced liver and kidney diseases, and advanced neurologic illnesses (e.g., Alzheimer's and Parkinson's disease). In the past decade, there has been tremendous growth of Palliative Medicine programs across the country. As the population of patients with serious illnesses increases, there is growing concentration on quality of care, including symptom management, meeting patients' goals regarding their medical care and providing various types of support, all of which are provided by Palliative Medicine. In this review article we define Palliative Medicine, describe care pathways and their applicability to Palliative Medicine, identify different models for Palliative Care and provide evidence for its impact on cost and quality of care.

Statewide Differences in Personality Associated with Geographic Disparities in Access to Palliative Care: Findings on Openness.

Background: Geographic disparities in access to palliative care cause unnecessary suffering near the end-of-life in low-access U.S. states. The psychological mechanisms accounting for state-level variation are poorly understood. Objective: To examine whether statewide differences in personality account for variation in palliative care access. Design: We combined 5 state-level datasets that included the 50 states and national capital. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. State-level personality differences in openness, conscientiousness, agreeableness, neuroticism, and extraversion were identified in a report on 619,387 adults. The Census and Gallup provided covariate data. Regression analyses examined whether state-level personality predicted state-level palliative care access, controlling for population size, age, gender, race/ethnicity, socioeconomic status, and political views. Sensitivity analyses controlled for rurality, nonprofit status, and hospital size. Results: Palliative care access was higher in states that were older, less racially diverse, higher in socioeconomic status, more liberal, and, as hypothesized, higher in openness. In regression analyses accounting for all predictors and covariates, higher openness continued to account for better state-level access to palliative care (ß = 0.428, p = 0.008). Agreeableness also emerged as predicting better access. In sensitivity analyses, personality findings persisted, and less rural states and those with more nonprofits had better access. Conclusions: Palliative care access is worse in states lower in openness, meaning where residents are more skeptical, traditional, and concrete. Personality theory offers recommendations for palliative care advocates communicating with administrators, legislators, philanthropists, and patients to expand access in low-openness states.

Oncology and Palliative Medicine: Providing Comprehensive Care for Patients With Cancer.

BACKGROUND: Despite the evidence for the fundamental need for palliative medicine services in the practice of oncology, integration of these medical specialties remains a clinical challenge. METHODS: We reviewed the current literature regarding the practice of palliative medicine in the field of oncology, examining randomized clinical trials of palliative medicine services in advanced cancer, models of palliative medicine delivery, studies of cost effectiveness, and national palliative medicine practice and referral guidelines. In this review, we describe the role of palliative medicine in oncology, including the timing of palliative medicine consultation, models of care delivery, and improvements in patient outcomes. RESULTS: Randomized controlled trials and national guidelines support early referral of patients with cancer to palliative medicine. Palliative medicine has a fundamental role in symptom management, distress relief, family and caregiver support, and advance care planning. Integration of palliative medicine in oncology improves patient outcomes and decreases healthcare costs. Early involvement of palliative medicine after the cancer diagnosis is supported by national guidelines, but barriers include variable referral patterns among oncologists and the need for an expanded palliative medicine workforce. CONCLUSION: Palliative medicine has a wide-ranging role in the spectrum of comprehensive cancer care-from patient diagnosis to survivorship. The entire multidisciplinary care team has a role in providing palliative care in inpatient and outpatient settings. An effective palliative medicine and oncology collaboration improves patient care and quality of life, has broad research and guideline support, and is cost effective.

Giant submandibular gland duct sialolith mimicking an impacted canine tooth.

Sialolithiasis is the most common disease affecting the salivary glands and accounts for 80% of salivary gland disorders. Chronic sialolithiasis promotes stone formation. Size of the salivary stones may range from 0.1 mm to 30 mm or be even bigger. Those salivary stones, the size of which exceeds 15 mm in any one dimension or 1 g in weight are classified as giant sialoliths. Giant sialoliths of the submandibular gland duct are rarely reported. Here, we report a case of a giant sialolith of the submandibular gland duct mimicking an impacted mandibular canine tooth on routine radiographic examination and its surgical management through an intraoral approach.

Depression in Older Adults: A Palliative Medicine Perspective.

This article aims to discuss the rapidly growing field of palliative medicine and its unique approach to treating depression in older adults.