Palliative and end-of-life care for patients with ovarian cancer.

Palliative care improves the quality of life of patients and their families through the prevention and treatment of distressing symptoms while addressing the psychological, social, and spiritual aspects of patient care. Emerging paradigms of delivery promote early involvement in the disease trajectory and specialty approaches to care. Interdisciplinary assessment and shared decision making are important components. Throughout the disease course, aggressive symptom management can improve patients' quality of life and their ability to tolerate and continue treatment. End-of-life care focuses on comfort, control, meaning, and support that become particularly intense when death is imminent.

Looking Back, and Ahead: A Call to Action for Increasing the Hospice and Palliative Medicine Specialty Pipeline.

Thanks to the efforts of many individuals and organizations, the field of Hospice and Palliative Medicine (HPM) has undergone unprecedented growth over the last two decades. To meet the needs of seriously ill patients and families in inpatient, outpatient community setting in the future, the field of HPM must develop innovative strategies to expand the specialist workforce pipeline. With 148 programs participating in the National Residency Matching Program and 285 matched applicants in 2019, the specialty of HPM can barely replace those who are retiring or leaving the field. We call for a renewed and coordinated effort to increase the applicant pool for HPM fellowship positions, as well as greater access to specialist HPM training through expanded traditional fellowship programs and innovative specialist training pathways. Without such an expansion, our specialty will struggle to serve those patients and families who need us most.

Revisiting 'awareness contexts' in the 21st century hospital: How fragmented and specialized care shape patients' Awareness of Dying.

In 1965, Glaser and Strauss (1965) offered the concept of "awareness contexts" to explain what patients in hospitals do or don't know about their death trajectories. Awareness ranges from closed (where patients are completely unaware and family and providers protect "the secret") to open (where all parties communicate openly and honestly). While closed awareness was the norm in 1960s, open awareness is now considered standard practice in US, a reflection of mounting evidence that patients, families, and providers benefit from clear and honest communication at end of life (Seale et al., 1997; Wright et al., 2008). Despite the known benefits of open awareness, many terminal patients remain unaware or confused about their prognoses (Chen et al., 2017). This paper asks why, in an era of open awareness, are patients and families uncertain about dying? To answer this question, we focus on an aspect of Glaser and Strauss's theory that remains relatively understudied by researchers, namely the role of institutional and organizational realities in shaping awareness contexts. Based on interviews with 43 family members of deceased patients who died at General Hospital in the Midwestern US, we argue that two related conditions in hospitals-the increased specialization of medical professionals and the fragmentation of patient care-serve as important context for the death awareness of patients and families.

Development of Curricular Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S.

CONTEXT: A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define curricular milestones (CMs) for hospice and palliative medicine (HPM) Fellowship Programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement entrustable professional activities previously developed by this group and new specialty-specific reporting milestones (RMs) for HPM developed through the Accreditation Council for Graduate Medical Education. OBJECTIVES: The objective of this study was to develop and vet CMs for HPM fellowships in the U.S. METHODS: A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing, and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep," "revise," or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. Eighty-four of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings. CONCLUSION: A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with entrustable professional activities and new specialty-specific RMs, these CMs offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

An innovative role for nurse practitioners in managing chronic disease.

Under the current care delivery model, persons with chronic illnesses, such as diabetes, are not receiving all recommended interventions and failing to meet targeted outcomes. The Chronic Care Model provides a framework for new approaches and roles for many members of the multidisciplinary team. Using the Chronic Care Model as a guide, a group of hospital-based clinics in an academic system incorporated nurse practitioners into the care model for patients with diabetes. Through use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, the pilot sample improved processes of care and clinical outcomes. Use of nurse practitioners in this model of care for chronically ill patient populations has economic implications, as the payers begin to pay for performance.

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States.

CONTEXT: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be "entrusted" to practice without supervision. A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Hospice and Palliative Medicine (HPM) EPAs. OBJECTIVE: The objective of this study was to describe the development of a set of consensus EPAs for HPM fellowship training in the United States. METHODS: A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3550 HPM physicians. Vetting feedback was reviewed, and survey data were statistically analyzed. Final EPA revisions followed from the multisource feedback. RESULTS: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors (46%). Respondents indicated that the set of 17 EPAs well represented the core activities of HPM physician practice (mean 4.72 on a five-point Likert scale) and considered all EPAs to either be "essential" or "important" with none of the EPAs ranking "neither essential, nor important." CONCLUSIONS: A set of 17 EPAs was developed using national input of practicing physicians and program directors and an iterative expert workgroup consensus process. The workgroup anticipates that EPAs can assist fellowship directors with strengthening competency-based training curricula.

Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study.

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.

Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital.

BACKGROUND: Evidence suggests palliative care consult services yield cost improvements; few studies have examined the impact of an inpatient palliative care unit on hospital costs. OBJECTIVE: This study estimates the cost avoidance of a single hospital's acute palliative care unit (APCU), building upon previous studies (1) by limiting pre-APCU costs to two days pre-APCU transfer, thereby minimizing bias from higher-cost first days of admission, and (2) by not limiting the study to cancer patients or patients who died, thereby presenting more comprehensive APCU costs. DESIGN: This retrospective study compares direct costs of care on an APCU with costs pre-APCU transfer from general medical units, intensive care units (ICU), and the emergency department (ED), and compares the direct costs of APCU patients with those of control patients. The data were entered into an SPSS(®) 17.0 (SPSS Inc., Chicago, IL) statistical software database. Paired and independent samples t-tests were conducted to test cost differences. SETTING/SUBJECTS: Study patients were admitted or transferred to the APCU from October 2008 through January 2009. Control patients were inpatients during the same time period and met several matching criteria. MEASUREMENTS: The hospital's finance department provided direct costs, case mix index (CMI), and geometric mean length of stay, and the Department of Quality and Resource Management provided patients' demographic and administrative data. RESULTS: Of 209 patients transferred to the APCU, 50% transferred from a medical unit, 32% from an ICU, and 18% from the ED. Annualized, the total cost avoidance realized by transfers to the APCU was $848,556, over half of which came from ICU to APCU transfers. CONCLUSIONS: Cost avoidance is realized when patients transfer to an APCU even when conservative pre-APCU cost measures are used and when patients with varying diagnoses and discharge outcomes are included. This study demonstrates a replicable methodology for estimating the financial impact of an APCU.

In-hospital mortality in patients older than 60 years with very low albumin levels.

CONTEXT: Low albumin levels have been associated with increased mortality, but few studies have looked at the mortality rates of patients with very low albumin levels. OBJECTIVES: The objective of this study was to determine the in-hospital mortality rates for patients older than 60 years with albumin levels <2.0 g/dL. METHODS: This was a retrospective study of 543 consecutive patients older than the age of 60 who had an albumin level <2.0 g/dL while admitted to Summa Akron City Hospital between July and November 2008. Data were obtained from hospital databases. Mortality rates were calculated for each albumin level and compared with the overall inpatient mortality for patients older than 60 years. Rates of discharge to home were calculated by albumin level. Cross-tabulations and correlations were conducted to determine the association between albumin level and mortality, and to assess the independent effects of total parenteral nutrition, dialysis, cancer, and end-stage renal disease. RESULTS: Patients with albumin levels between 1.0 and 1.4 had a 41% in-hospital mortality rate, with only 16% of the patients being discharged to home. Patients with albumin levels between 1.5 and 1.9 had a 21% mortality rate, with 33% of patients discharged to home. Overall hospital mortality for patients older than 60 years was 6% during the study period. Total parenteral nutrition, cancer, dialysis, and end-stage renal disease were not independent risk factors for mortality in this study. CONCLUSION: An albumin level is readily obtained across all areas of the hospital and provides a simple and useful aid in identifying patients at high risk of a poor hospital outcome.

A 4-year integrated curriculum in palliative care for medical undergraduates.

In order to graduate physicians prepared to effectively address clinical issues in palliative medicine and to comply with LCME requirements, the Northeastern Ohio Universities Colleges of Medicine and Pharmacy (NEOUCOM) integrated a coordinated four-year palliative care (PC) curriculum. This report describes the development of the longitudinal curriculum and provides helpful resources and strategies to guide clinicians and administrators undertaking similar efforts. This is a retrospective, descriptive report based on data collected throughout development of the new curriculum. A Palliative Care Advisory Committee initiated development of curricula in PC. An Office of Palliative Care was established to assess and coordinate offerings. Curriculum transformation was based on best practices. Two cornerstone pieces are highlighted: a mandatory hospice experience and a case based small group discussion prior to graduation.