ABSTRACT
Existential distress is commonly experienced by patients diagnosed with a life-threatening illness. This condition has been shown to adversely impact quality of life and is correlated with increased suicidal ideation and requests for hastened death. While palliative care teams are experienced in treating depression and anxiety, existential distress is a distinct clinical condition for which traditional medications and psychotherapy approaches demonstrate limited efficacy or duration of effect. Psychedelic drugs, including psilocybin and lysergic acid diethylamide (LSD), in conjunction with psychotherapy have been shown to produce rapid and sustained reductions in existential and psychiatric distress and may be a promising treatment for patients facing existential distress in palliative care settings. In this narrative review article, we describe the history of psychedelic medicine including early studies and the modern wave of research over the past 20 years, which includes high quality clinical trial data. This review outlines specific considerations for therapeutic application of psilocybin including pharmacokinetics, patient selection, dosing, protocol designs, and safeguards to reduce potential adverse effects to help guide future psychedelic practitioners. With growing public interest and evolving state level policy reforms allowing access to psychedelic treatments, it is critical for palliative care providers to gain familiarity with the current state of science and the potential of psilocybin assisted psychotherapy in the treatment of existential distress.
ABSTRACT
RATIONALE: Effective interventions to prevent burnout among intensive care unit (ICU) clinicians are urgently needed. Death Cafés, group discussions about death, build a sense of community and create a space for reflection on distressing events. OBJECTIVE: To assess whether participation in regular Death Cafés can prevent burnout in ICU clinicians (physicians, nurses, pharmacists, therapists). METHODS: A randomized clinical trial was conducted from July 2020-December 2022 in ten ICUs in Louisiana. Subjects were randomized to attend four psychotherapist-facilitated, virtual Death Cafés or to a control arm. MEASUREMENTS AND MAIN RESULTS: The primary outcome was burnout defined by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) at 6 months. Depression and anxiety scores were measured as well as qualitative data on stressors, coping, and Death Café experience. Among 340 clinicians screened and consented (171 physicians; 169 non-physicians), 251 participated (mean age 31.0ï±6.8 years, 63% female, 72% white, 37% nurses, 27% residents, 25% interns, 11% other). Burnout prevalence was 19% at baseline. Of 136 participants who completed 6-month follow-up, no significant differences were found between intervention and control for the primary outcome (18% versus 25%, unadjusted OR 0.64 [95% CI 0.26-1.57], p=0.33). There were no differences in anxiety or depression. Notably, the study was limited by an inability to achieve target enrollment and high attrition rate (46%). CONCLUSIONS: Virtual Death Cafés were unable to reduce burnout, although the study was underpowered to detect differences between groups. Clinical trial registered with Clinicaltrials.gov (NCT04347811).
ABSTRACT
Background: Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (Truvada) is highly effective at preventing human immunodeficiency virus (HIV) transmission in high-risk populations, including in men who have sex with men (MSM). In 2019, the US Preventive Services Task Force released an A recommendation to offer PrEP to persons at high risk of HIV acquisition. Despite the demonstrated efficacy of PrEP, areas with high HIV incidence, such as Louisiana, have historically had low PrEP prescription rates. The objective of this study was to determine the factors associated with whether providers in the Ochsner Health System (OHS) discussed PrEP with HIV-negative MSM patients. Methods: Investigators extracted electronic medical record data on all HIV-negative MSM patients who had at least one outpatient visit at OHS between July 1, 2012 and July 1, 2016 and manually reviewed a random sample of 115 charts. Results: Subjects were predominantly Caucasian (75.7%) with a mean age of 37.6 years. A PrEP discussion was documented for 34 (29.6%) patients. Multivariate modeling showed that having a PrEP discussion was associated with 3 factors: being assigned to a primary care provider known to specialize in MSM care (odds ratio [OR] 5.05, 95% confidence interval [CI] 1.81-14.10; P=0.002), having a documented history (positive or negative) of sexually transmitted infection vs no documentation (OR 5.41, 95% CI 1.80-16.23; P=0.003), and having documentation of condom use (consistent or inconsistent) vs no documentation (OR 3.32, 95% CI 1.27-8.74; P=0.015). Conclusion: Despite evidence that PrEP significantly reduces sexual transmission of HIV in MSM, PrEP discussions with MSM across OHS were undesirably low. Additional resources need to be aimed at increasing PrEP uptake and should focus on providing skills-based training and education in PrEP and MSM care to healthcare providers. With increased knowledge of and familiarity with PrEP prescribing guidelines, more providers will be better equipped to identify at-risk patients and to discuss prevention options such as PrEP.