Rest in Peace or in Pieces: Post-Mortem Care Options in U.S. Advance Directives.

Advance Directives (ADs) have traditionally focused on documenting patients' end-of-life (EOL) care preferences. Recently, discussions surrounding post-mortem care as an additional aspect of EOL care planning have gained attention. This study examined ADs across all 50 states and the District of Columbia (referred to as "entities"), assessing their inclusion of two post-mortem categories: funeral planning and anatomical gifts. Results revealed that 29% of entities offered options from both categories, 43% provided options from only one of the categories, and 27% lacked options from either category. Unexpectedly, only one entity (2%) provided all post-mortem options from both categories. These findings suggest a lack of consistency in the availability of post-mortem options across ADs. By emphasizing the importance of comprehensive EOL care planning, this study provides valuable insights into the necessity for AD standardization, particularly regarding post-mortem preferences for patients who choose to express them.

Knowledge, Attitudes, and Beliefs Regarding Medical Cannabis Among Patients and Providers in Florida's Long-Term Care Facilities.

OBJECTIVES: Medical cannabis (MC) has been found effective in treating multiple symptoms commonly experienced by older adults; however, residents in long-term care (LTC) often lack access to MC products. This study seeks to identify patterns and barriers to recommending MC to patients and to explore the knowledge and attitudes toward MC use among patients and providers. METHODS: The quantitative portion of this study employed a survey to assess the knowledge of, attitudes toward, and barriers to MC among 126 providers in Florida LTC. Frequencies were reported, bivariate associations were analyzed, and a final regression model predicting MC knowledge was tested. In-depth interviews were conducted with 25 LTC patients, and content was analyzed using the RADaR method. RESULTS: The age of the providers ranged from 21 to 74; 74% were female, 18% were Black/African American, and 17% reported Hispanic ethnicity. Less than half (37.2%) felt they received adequate training on MC. Having accurate knowledge about MC was associated with greater confidence in answering patients' questions (p=0.002). Although most providers (94.2%) felt MC is a viable treatment option, the main barriers to recommending it to patients were a lack of proper training or clinical guidelines. Regarding patients, 16% reported ever using MC, and less than half (32%) had knowledge of MC or how to obtain products. Many believed it could help with symptoms and would consider its use if recommended by a doctor. However, they reported that MC was rarely recommended by providers and that they knew little about the use of this therapy. CONCLUSION: This study underscores access challenges among seniors in LTC who might benefit most from MC's therapeutic properties. Complex MC policy implementation issues are discussed. State and federal policy issues around cannabis contribute to limited research on the therapeutic uses of cannabis, as well as the MC access problem addressed in this study.

Advance Directives Revisited (2002 vs 2023): Are We Closer to Uniformity?

BACKGROUND AND OBJECTIVES: Advance directives (ADs) are based on state-specific statutes that vary in structure, terminology, and options. This variability leads to inconsistent end-of-life (EOL) care for patients who have executed an AD in 1 state but fall ill in another state. This study revisits a 2002 article that identified considerable differences in ADs to determine whether ADs have become more uniform. RESEARCH DESIGN AND METHODS: ADs from all 50 states and the District of Columbia were examined to determine the frequency of document types and seven key issues. The results were compared to the 2002 study using nonparametric approaches. Mean numbers of key issues were compared using t-tests and 1-way analysis of variance. RESULTS: Consistent with 2002, 3 states in 2023 provide statutes for a healthcare power of attorney (HCPOA). However, states offering a combined HCPOA, and living will (LW), deemed an advance directive for healthcare (ADHC), increased from 13 to 30. Between both studies, Long-Term Care increased significantly in LW and ADHC, whereas Artificial Sustenance significantly increased in LW. Despite the rising prevalence of Alzheimer's in the United States, only 10% of states included this issue in 2023. DISCUSSION AND IMPLICATIONS: Despite evolving healthcare trends, minimal revisions have been made to ADs since 2002. This lack of uniformity can cause confusion regarding the proper understanding of EOL wishes. The authors recommend that the Uniform Act for Advance Directives be revisited to promote greater uniformity in ADs and ensure that individuals' preferences are understood and respected across different states.

Trends in HIV-Related Services Offered by Substance Abuse Treatment Facilities.

Introduction In the United States, persons who inject drugs (PWID) represent an increasingly vulnerable population, with a high risk of HIV transmission related to needle sharing. This paper aims to investigate the availability of HIV-related services within substance abuse treatment facilities while emphasizing the need for implementing comprehensive harm-reduction strategies in such facilities. Methods This study explores the prevalence and trends regarding HIV-related services within substance abuse treatment facilities in the United States including testing, counseling, early intervention, and medication provision. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed in order to assess trends in HIV-related services from 2013 to 2020. Results Facility response rates revealed an increase in the availability of HIV testing and specialized programs for individuals with HIV. However, there was a contrasting trend with the decline in early intervention and counseling services, only with a slight increase in 2020. Additionally, government-owned facilities demonstrated superior performance in delivering HIV services compared to private facilities. Conclusion This study highlights the dire need for implementing routine opt-out HIV testing within substance abuse treatment facilities in order to identify new cases. Additionally emphasized is the importance of early intervention for this at-risk population. To effectively address these challenges, we suggest considering the adoption of the "Seek, Test, Treat, Retain" model as a potential solution. Increasing access to HIV-related services within substance abuse facilities requires enhanced resource allocation as well as integrated programs. Identifying deficiencies in HIV service integration is crucial to enhancing care and reducing HIV transmission among PWID.

Inhalational Heroin Use and Leukoencephalopathy: A Case Report.

Heroin-induced leukoencephalopathy (HLE) is a rare condition with acute and chronic outcomes ranging from mild neurological symptoms to severe neurological deficits and death. HLE is caused by cerebral white matter damage secondary to exposure to toxic agents such as chemotherapeutic drugs, environmental toxins, and drugs of abuse. Here, we present the case of a 20-year-old woman with a past medical history significant for bipolar disorder and opioid use who presented to the emergency department with ataxia, involuntary movements, and altered mental status secondary to inhalational heroin use. The patient presented with symptoms including agitation, tremors, speech difficulty, confusion, memory loss, and weakness. Magnetic resonance imaging (MRI) showed diffuse cerebral atrophy and electroencephalography (EEG) was significant for cerebral dysfunction in the left hemisphere and diffuse encephalopathy. The patient was treated with intravenous (IV) steroids, vitamins, and fluids but failed to show improvement. She was subsequently discharged to hospice 17 days after admission. There are few reported cases of toxic leukoencephalopathy due to heroin inhalation. The patient's young age and presentation following one month of abstinence are particularly unique as she suffered an acute decompensation with severe, lasting neurological deficits. This case highlights a potential presentation of HLE and seeks to increase clinical recognition in patients with a recent history of substance use and unexplained neurological symptoms.

Fearing Pain at the End of Life: A Review of Advance Directives.

BACKGROUND: Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain. METHODS: An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life. RESULTS: Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death. CONCLUSION: The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.

Student Perspectives on Implementing Stop the Bleed Training into Medical School Curriculum.

BACKGROUND: Following the Hartford Consensus guidelines and recommendations, third-year medical students from a single institution were offered an optional Stop the Bleed (STB) training course in August 2018. The aim of this study was to assess medical students' confidence in performing bleeding control techniques and teaching others after completing the STB course. The secondary goal was to assess student perception on integrating mandatory STB training into the medical school curriculum. MATERIALS AND METHODS: A 24-question survey using a 4-point Likert scale was administered to all medical students who completed STB training. Students were anonymously asked to self-report their confidence in performing bleeding control techniques, training others after STB training, and their perception on integrating STB training into medical school curriculum. RESULTS: After completing the STB course, 95% of students were comfortable applying a tourniquet, 92% of students were confident in packing wounds, and 99% of students could apply direct pressure to wounds to stop bleeding. Overall, 94% of students reported that STB training would be helpful for their clinical rotations. CONCLUSION: These results demonstrate that medical students are positively impacted by Stop the Bleed courses and validate that the implementation of mandatory STB courses into medical school curriculum will improve medical students' knowledge and skills for hemorrhage control.

Sociodemographic Disparities In Access To COVID-19 Vaccines Upon Initial Rollout In Florida.

In this study we explored sociodemographic disparities in COVID-19 vaccine access upon initial rollout at Publix grocery store locations throughout Florida in January 2021. Florida officials reported that they chose Publix stores for the vaccine rollout because the chain has so many stores in the state and was considered at the time to be better prepared than other retailers. Data on education levels, ethnicity, race, percentage at or below the poverty level, and percentage single-parent households were collected from the 2019 census for 974 Florida ZIP codes. We used hotspot analysis to measure spatial clustering of Publix vaccination sites per 100,000 people. We identified hot spots (areas with greater vaccine availability) in moderately populated areas where the population was significantly older, richer, and Whiter than in areas of lower vaccine availability (cold spots). Cold spots were identified in areas of low and high population density, areas with a higher proportion of Hispanic residents, and areas with a higher proportion of single-parent households, including Miami-Dade County and inland regions of Florida. Multivariate analysis showed strong associations between the number of vaccination sites in a ZIP code and race and ethnicity and a weaker association with percentage of residents at or below the poverty level. Future vaccine distribution should continue to be monitored through a socioeconomic lens to help prevent unequal access.

Exploring Quality of Life in End-of-Life Discussions.

Advance directives (ADs) allow individuals to legally determine their preferences for end-of-life (EOL) medical treatment and designate a health-care proxy to act on their behalf prior to losing the cognitive ability to make informed decisions for themselves. An interprofessional group of researchers (law, nursing, medicine, and social work) conducted an exploratory study to identify the differences in quality-of-life (QOL) language found within the AD state statutes from 50 US states and the District of Columbia. Data were coded using constant comparative analysis. Identified concepts were grouped into 2 focus areas for EOL discussions: communication/awareness of surroundings and activities of daily living. Language regarding communication/awareness of surroundings was present in the half of the statutes. Activities of daily living were addressed in only 18% of the statutes. Only 3 states (Arkansas, Nevada, and Tennessee) specifically addressed QOL. Patients are best served when professionals, regardless of discipline, can share and transform knowledge for patients in times of crisis and loss in ways that are empathetic and precise. Interprofessional collaborative practice (IPCP) comprises multiple health workers from different professional backgrounds working together with patients, families, and communities to deliver the highest quality of care. One of the major competencies of IPCP encompasses values and ethics. Interprofessional collaborative practice is offered as the means to deliver person-centered value-based care when facilitating these crucial dialogs and making recommendations for change.

Resident Knowledge and Perception of Pain Management.

Chronic pain involves a complex mechanism that afflicts 50 million adults in the United States and incurs societal costs upwards of $560 billion annually. The consequences of this epidemic have resulted in an epidemic of its own, with the opioid crisis becoming a top priority in healthcare. Historically, the sub-optimal practices of overprescribing opioids and inadequate monitoring of iatrogenic addiction have contributed to this problem. If progress is to be made in this area, it is imperative that we examine how future physicians are being trained to manage pain. We examined internal medicine resident knowledge regarding pain as well as their satisfaction with medical school preparation in this regard using two surveys: The Knowledge and Attitudes Survey Regarding Pain (KASRP) and The Medical School Pain Curriculum Survey (MSPCS). Residents scored an overall 60.7% on the knowledge assessment survey, and less than 50% of respondents agreed that their medical school curriculum had prepared them sufficiently. This suggests that improvements can be made in medical school curricula regarding pain management education to better train physicians on how to manage pain, particularly in an era that demands expertise in this area.

Complicated postoperative course secondary to kratom withdrawal: a case report.

We herein report a case of a 55-year-old female with an unusual case of post-operative kratom withdrawal. The patient's withdrawal symptoms subsequently contributed to complications and admission to the intensive care unit. Features of this case are discussed, alongside the management of kratom withdrawal and the implications of supplementation with unregulated herbal medications.

Underutilization of Aspirin in Patients With Advanced Colorectal Polyps.

BACKGROUND: Colorectal cancer is the third-most common cause of cancer deaths in the United States, and advanced colorectal polyps are a major risk factor. Although there are no large-scale individual trials designed a priori to test the hypothesis, in meta-analyses of trials in primary prevention of cardiovascular disease, aspirin reduces risk of colorectal cancer. The US Preventive Services Task Force used a microsimulation model, including baseline risk factors, and concluded that aspirin reduces risk of colorectal cancer by 40%. Their guidelines suggest that without a specific contraindication, clinicians should routinely prescribe aspirin to patients with advanced colorectal polyps. METHODS: Written informed consent was obtained, and brief telephone interviews were conducted by trained interviewers for 84 men and women with biopsy-proven advanced colorectal polyps from 55 clinical practices. RESULTS: Of the 84, 39 (46.4%) were men. The mean age was 66 with a range from 41 to 91 years. Among the 84, 36 (42.9%) reported taking aspirin. CONCLUSIONS: These data suggest underutilization of aspirin by patients with advanced colorectal polyps. These data pose major challenges that require multifactorial approaches by clinicians and their patients, which include therapeutic lifestyle changes, adjunctive drug therapies, and screening. Lifestyle changes include treating overweight status and obesity and engaging in regular physical activity; adjunctive drug therapies include aspirin. These multifactorial approaches will be necessary to achieve the most good for the most patients with regard to prevention, as well as, early diagnosis and treatment of colorectal cancer in patients with advanced colorectal polyps.

Advance Directives in Hospice Healthcare Providers: A Clinical Challenge.

BACKGROUND: On a daily basis, healthcare providers, especially those dealing with terminally ill patients, such as hospice workers, witness how advance directives help ensure the wishes of patients. They also witness the deleterious consequences when patients fail to document the care they desire at their end of life. To the best of our knowledge there are no data concerning the prevalence of advance directives among hospice healthcare providers. We therefore explored the prevalence and factors influencing completion rates in a survey of hospice healthcare providers. METHODS: Surveys that included 32 items to explore completion rates, as well as barriers, knowledge, and demographics, were e-mailed to 2097 healthcare providers, including employees and volunteers, at a nonprofit hospice. RESULTS: Of 890 respondents, 44% reported having completed an advance directive. Ethnicity, age, relationship status, and perceived knowledge were all significant factors influencing the completion rates, whereas years of experience or working directly with patients had no effect. Procrastination, fear of the subject, and costs were common reasons reported as barriers. Upon completion of the survey, 43% said they will now complete an advance directive, and 45% will talk to patients and families about their wishes. CONCLUSION: The majority of hospice healthcare providers have not completed an advance directive. These results are very similar to those for other healthcare providers treating patients with terminal diseases, specifically oncologists. Because, at completion, 43% said that they would now complete an advance directive, such a survey of healthcare providers may help increase completion rates.

Dying tax free: the modern advance directive and patients' financial values.

Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit.