Development and testing of a frailty-focused communication (FCOM) aid for older adults.

The concept of frailty as it pertains to aging, health and well-being is poorly understood by older adults and the public-at-large. We developed an aging and frailty education tool designed to improve layperson understanding of frailty and promote behavior change to prevent and/or delay frailty. We subsequently tested the education tool among adults who attended education sessions at 16 community sites. Specific aims were to: 1) determine acceptability (likeability, understandability) of content, and 2) assess the likelihood of behavior change after exposure to education tool content. Results: Over 90% of participants "liked" or "loved" the content and found it understandable. Eighty-five percent of participants indicated that the content triggered a desire to "probably" or "definitely" change behavior. The desire to change was particularly motivated by information about aging, frailty and energy production. Eight focus areas for proactive planning were rated as important or extremely important by over 90% of participants.

The earlier the better: the role of palliative care consultation on aggressive end of life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients.

PURPOSE: To evaluate the role of specialty palliative care consultation (PCC) on end of life care outcomes among terminally ill gynecologic oncology patients. METHODS: Retrospective chart review of currently deceased gynecologic oncology patients seen at a single, academic institution between October 2006 and October 2016. Clinical characteristics and outcomes were examined using descriptive statistics and logistic regression. RESULTS: Two hundred and four patients were eligible. Forty-one percent underwent at least one marker of aggressive care at the end of life. Most (53%) had a PCC prior to death, and of these most were inpatient (89%). Patients with a PCC had higher odds of hospice enrollment before death (OR 2.55, p = 0.016) and higher odds of advance care planning documentation before death (OR 6.79, p = < 0.001). Among patients with an inpatient PCC, 44% underwent a marker of aggressive medical care at the end of life and 82% enrolled in hospice before death. Among patients with an outpatient PCC, 25% underwent a marker of aggressive medical care at the end of life and 92% enrolled in hospice before death. Patients with outpatient PCC were engaged in palliative care longer than patients with inpatient PCC (median 106 days vs. 33 days prior to death). CONCLUSIONS: PCC increased hospice enrollment and advance care planning documentation. Patients with outpatient PCC had lower rates of aggressive medical care and higher rates of hospice enrollment when compared to inpatient PCC. Location of initial PCC plays an important role in end of life care outcomes.

Heartland virus-associated death in tennessee.

BACKGROUND: Heartland virus (HRTV) is a tick-borne phlebovirus recently described in Missouri that is associated with fever, leukopenia, and thrombocytopenia. The virus has also been detected in Ambylomma americanum ticks. METHODS: Here we report the first fatal case of HRTV disease in an 80-year-old Tennessee resident. He was hospitalized with fever, confusion, leukopenia, and thrombocytopenia and developed multiorgan failure and hemorrhage. A tick-borne illness was suspected and testing for ehrlichiosis was negative. He died on hospital day 15, and autopsy specimens were tested for various pathogens as part of an unexplained death evaluation. RESULTS: HRTV antigens were detected in postmortem spleen and lymph nodes by immunohistochemistry, and HRTV was detected in premortem blood by reverse transcription polymerase chain reaction and by isolation in cell culture. CONCLUSIONS: This case demonstrates that HRTV infection can cause severe disease and death and expands the geographic range of HRTV within the United States.

Senior adult oncology, version 2.2014: clinical practice guidelines in oncology .

Cancer is the leading cause of death in older adults aged 60 to 79 years. The biology of certain cancers and responsiveness to therapy changes with the patient's age. Advanced age alone should not preclude the use of effective treatment that could improve quality of life or extend meaningful survival. The challenge of managing older patients with cancer is to assess whether the expected benefits of treatment are superior to the risk in a population with decreased life expectancy and decreased tolerance to stress. These guidelines provide an approach to decision-making in older cancer patients based on comprehensive geriatric assessment and also include disease specific issues related to age in the management of some cancer types in older adults.

Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors.

OBJECTIVE: In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes. METHODS: A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (

Improving Medical and Nurse Practitioner Student Confidence and Clinical Skill in Advance Care Plan Development: A Multidisciplinary Mentorship Model.

BACKGROUND: Advance care planning (ACP) is an integral aspect of patient-centered care, however medical (MD) and Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) students receive minimal education on how to facilitate ACP discussions and ultimately feel uncomfortable having these discussions with patients.1-4 The aim of this project was to increase MD and AGACNP students' perceived ability and confidence in leading ACP conversations through an ACP educational program called the Letter Project Pilot (LPP). METHODS: The LPP consisted of faculty-supervised interactions in the inpatient setting during which students were able to lead ACP discussions with patients by guiding them through an advance directive worksheet that was structured in the format of a letter. Student participants were recruited from the MD and AGACNP programs associated with the academic medical center. Patients were recruited from inpatient medicine and geriatrics units at the academic medical center. At the end of the 3-month pilot, a voluntary, anonymous REDCap survey was used to evaluate 2 primary outcomes of interest:1) the association of the LPP pilot on perceived ACP skills, and 2) the perceived impact of the LPP pilot on ACP in future practice. RESULTS: Students perceived that their experiences positively enhanced their current ACP skills and their ability to have ACP conversations in their future practice. CONCLUSION: The results support that the LPP is a scalable, cost-effective project that increases students' perceived ability and confidence in leading ACP conversations.

Palliative Care Exposure Relative to Predicted Risk of Six-Month Mortality in Hospitalized Adults.

CONTEXT: The optimal strategy for implementing mortality-predicting algorithms to facilitate clinical care, prognostic discussions, and palliative care interventions remains unknown. OBJECTIVES: To develop and validate a real-time predictive model for 180 day mortality using routinely available clinical and laboratory admission data and determine if palliative care exposure varies with predicted mortality risk. METHODS: Adult admissions between October 1, 2013 and October.1, 2017 were included for the model derivation. A separate cohort was collected between January 1, 2018 and July 31, 2020 for validation. Patients were followed for 180 days from discharge, and logistic regression with selected variables was used to estimate patients' risk for mortality. RESULTS: In the model derivation cohort, 7963 events of 180 day mortality (4.5% event rate) were observed. Median age was 53.0 (IQR 24.0-66.0) with 92,734 females (52.5%). Variables with strongest association with 180 day mortality included: Braden Score (OR 0.83; 95% CI 0.82-0.84); admission Do Not Resuscitate orders (OR 2.61; 95% CI 2.43-2.79); admission service and admission status. The model yielded excellent discriminatory ability in both the derivation (c-statistic 0.873; 95% CI 0.870-0.877; Brier score 0.04) and validation cohorts (c-statistic 0.844; 95% CI 0.840-0.847; Brier score 0.072). Inpatient palliative care consultations increased from 3% of minimal-risk encounters to 41% of high-risk encounters (P < 0.01). CONCLUSION: We developed and temporally validated a predictive mortality model for adults from a large retrospective cohort, which helps quantify the potential need for palliative care referrals based on risk strata. Machine learning algorithms for mortality require clinical interpretation, and additional studies are needed to design patient-centered and risk-specific interventions.

Barriers and Facilitators to Discussing Goals of Care among Nephrology Trainees: A Qualitative Analysis and Novel Educational Intervention.

Background: Goals of care (GOC) conversations are critical to advance care planning but occur infrequently in nephrology. National workshops have improved trainee comfort with initiating GOC conversations but lack interface with palliative subspecialists and can incur travel-related costs. We developed an educational intervention focused on GOC conversations for nephrology trainees that incorporated into routine schedules and offered feedback from palliative subspecialists. Objective: To explore barriers and facilitators to discussing GOC and uncover perceptions of GOC-related behavior change post-intervention. Design: Qualitative study. Setting/Subjects: Sixteen nephrology trainees at an academic medical center. Measurements: Analyses of semistructured interviews occurred in phases: (1) isolation of quotes; (2) development of a coding system; and (3) creation of a framework of interrelationships between quotes using an inductive/deductive approach. Results: We captured the following themes: (1) prior knowledge (ability to define GOC, knowledge of communication frameworks and prognostic data, exposure to outpatient GOC conversations; (2) attitudes related to GOC conversations (responsibility, comfort, therapeutic alliance, patient preparedness, partnership with care teams); and (3) potential change in behaviors (increased likelihood to initiate GOC conversations early, more accurate identification of patients appropriate for a GOC conversation). Conclusions: Prior knowledge of, exposure to, and attitudes toward advance care planning were key determinants of a nephrology trainees' ability to initiate timely GOC conversations. After our intervention, trainees reported increased comfort with and likelihood to initiate GOC conversations and an improved ability to identify appropriate candidates. Our intervention may be a novel, feasible way to coach nephrologists to initiate timely GOC conversations.

Creating New Opportunities to Educate Families on the Impact of Frailty and Cognitive Impairment in a Trauma Intensive Care Unit: Results of a Quality Improvement Project.

BACKGROUND: Older adults comprise a rapidly growing proportion of admissions to acute care hospitals and trauma centers. Older adults admitted to a trauma intensive care unit (TICU) often have a more complicated inpatient and posthospital course. This is the most pronounced in frail elders with cognitive dysfunction. We aimed at integrating validated screening instruments for physical frailty and cognitive impairment into the standard nursing assessment of all older trauma patients admitted to our TICU and stepdown unit. OBJECTIVES: Our goal, for positive screens, was to trigger earlier referrals to palliative care for patient and family education on the range of likely clinical outcomes. METHODS: In February 2015, our study team trained bedside trauma nurses to implement a validated frailty screening process on all patients at least 65 years of age or older who were admitted to the TICU and stepdown unit. Between March and May 2015, the number of older adults admitted, mechanism of injury, numbers of patients screened, and positive screens, along with volume of palliative care referrals, were tracked. RESULTS: During the three-month period, the mean age of all older admissions (N = 131) was 75.5, of which 49% were screened. Among the patients screened, 38% screened positive for frailty, 45% screened positive for possible dementia, and 23% screened positive for both conditions. Palliative care consultations for older adults increased from 13% (before study) to 33% during the study period. CONCLUSION: A screening process designed for older adults to assess both physical frailty and cognitive impairment can be standardized into the routine care of older adults admitted to a busy trauma service. Positive screens can serve as a trigger for earlier palliative care assessments, with opportunities for educating patients and their families on the range of clinical trajectories that these vulnerable patients face.

Utilization of palliative care services for cardiac arrest patients undergoing therapeutic hypothermia: A retrospective analysis.

BACKGROUND: Palliative care (PC) services are integral to the care of patients with advanced medical illnesses. Given the significant morbidity and mortality associated with cardiac arrest, we sought to measure the use and impact of PC in the care of patients treated with therapeutic hypothermia (TH). METHODS: We conducted a retrospective study of 317 consecutive patients undergoing TH after cardiac arrest. We compared intensive care unit (ICU) characteristics and clinical outcomes of subjects who received PC consultation (n=125) to those who did not (n=192). RESULTS: The proportion of TH patients with PC consultations increased to greater than 60% by 2013, corresponding to our institution's expansion of PC services, development of a dedicated PC unit, and integration of this service into our published TH protocol. In the TH population, time to return of spontaneous circulation (ROSC) was associated with higher inpatient mortality (p<0.001) and placement of a PC consult (p=0.011). TH patients who received PC consultation had longer ICU stays (p=0.034), more ventilator days (p<0.001), and higher inpatient mortality (p<0.001). When these measures were analyzed cohort-wide comparing all TH patients pre- and post-2013, at which time the frequency of PC consultation had dramatically increased, there were no statistically significant differences in ICU care or outcomes. CONCLUSION: In our population of cardiac arrest patients undergoing TH, the utilization of PC services has increased over time, particularly for those patients with high morbidity and mortality. Future randomized studies may further delineate optimal patient selection for PC consultation to better facilitate goals of care discussions and timely medical decision-making.

Care of the Critically Ill Burn Patient. An Overview from the Perspective of Optimizing Palliative Care.

Burn specialists have long recognized the need for and have role modeled a comprehensive approach incorporating relief of distress as part of care during critical illness. More recently, palliative care specialists have become part of the healthcare team in many U.S. hospitals, especially larger academic institutions that are more likely to have designated burn centers. No current literature describes the intersection of palliative care and burn care or integration of primary and specialist palliative care in this unique context. This Perspective gives an overview of burn care; focuses on pain and other symptoms in burn intensive care unit settings; addresses special needs of critically ill burned patients, their families, and clinicians for high-quality palliative care; and highlights potential benefits of integrating primary and specialist palliative care in burn critical care. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature were searched, and an e-mail survey was used to obtain information from U.S. Burn Fellowship Program directors about palliative medicine training. The Improving Palliative Care in the Intensive Care Unit Project Advisory Board synthesized published evidence with their own research and clinical experience in preparing this article. Mortality and severe morbidity for critically ill burned patients remains high. American Burn Association guidelines lay the foundation for a robust system of palliative care delivery, embedding palliative care principles and processes in intensive care by burn providers. Understanding basic burn care, challenges for symptom management and communication, and the culture of the particular burn unit, can optimize quality and integration of primary and specialist palliative care in this distinctive setting.