Top Ten Tips Palliative Care Clinicians Should Know About Delivering Specialty-Aligned Palliative Care.

Specialty-aligned palliative care (SAPC) refers to interprofessional palliative care (PC) that is delivered to a specific population of patients in close partnership with other primary or specialty clinicians. As evolving PC models address physical, psychosocial, and spiritual suffering across illnesses and settings, PC clinicians must acquire advanced knowledge of disease-specific symptoms, common treatments, and complications that impact prognosis and outcomes. The tips provided in this article draw on the experience and knowledge of interprofessional PC and other specialist clinicians from diverse institutions across the United States who have developed and studied SAPC services across different disease groups. Recommendations include focusing on approaching specialty team partnerships with humility, curiosity, and diplomacy; focusing on patient populations where PC needs are great; clarifying how work and responsibilities will be divided between PC and other clinicians to the extent possible; using consults as opportunities for bidirectional learning; and adapting workflows and schedules to meet specialty team needs while managing expectations and setting limits as appropriate. Furthermore, to provide effective SAPC, PC clinicians must learn about the specific symptoms, prognoses, and common treatments of the patients they are serving. They must also build trusting relationships and maintain open communication with patients and referring clinicians to ensure integrated and aligned PC delivery.

Reconnecting: Strategies for Supporting Isolated Older Adults during COVID-19 through Tele-palliative Care.

The COVID-19 pandemic has resulted in unprecedented levels of social isolation which has negatively impacted older patients in particular on multiple levels. We present a case of an older patient with several complex psychosocial issues who was hospitalized and died from COVID-19. The social isolation required during the pandemic compounded patient and family stressors and diminished the patient's access to clinicians and to his usual support network and coping strategies. We describe how technology and tele-palliative care were utilized to reconnect the patient with clinicians and family and to provide clinical care that enhanced coping skills and support. Using telemedicine to restructure the approach to care was crucial in improving multiple domains of care and can be considered a resource for caring for older adults, especially during the challenging times brought on by the COVID-19 pandemic.

NCCN Guidelines® Insights: Palliative Care, Version 2.2021.

Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.

Resurrecting the Hospital Autopsy: Impact of an Office of Decedent Affairs on Consent Rates, Providers, and Next-of-Kin.

CONTEXT.­: Autopsy rates have decreased dramatically despite providing important clinical information to medical practices and social benefits to decedents' families. OBJECTIVE.­: To assess the impact of an institutional Office of Decedent Affairs (ODA), a direct communication link between pathology and decedents' families, on hospital autopsy consent rates, autopsy-related communication, practitioner views, and next-of-kin experiences. DESIGN.­: A before and after study involving all hospital decedents whose deaths did not fall within the jurisdiction of the medical examiner's office from 2013 to 2018. A pathology-run ODA launched in May 2016 to guide next-of-kin through the hospital death process (including autopsy-related decisions) and serve as the next-of-kin's contact for any subsequent autopsy-related communication. Critical care and hematology/oncology practitioners were assessed for their autopsy-related views and decedents' next-of-kin were assessed for their autopsy-related experiences. Autopsy consent rates for non-medical examiner hospital deaths, autopsy-related communication rates, practitioner views on the role and value of autopsy, and next-of-kin autopsy experiences and decisions factors were compared prior to and after ODA launch. RESULTS.­: Autopsy consent rates significantly increased from 13.2% to 17.3% (480 of 3647 deaths versus 544 of 3148 deaths; P < .001). There were significant increases in the rate of autopsy-related discussions and bereavement counseling provided to decedents' families. Practitioner views on the positive role of autopsy for any hospital death and those with advanced stage cancer also significantly increased. Next-of-kin indicated more consistent autopsy-related discussions with the potential benefits of autopsy discussed becoming key decision factors. CONCLUSIONS.­: An ODA improves hospital autopsy consent rates, autopsy-related communication, providers' autopsy-related views, and next-of-kins autopsy experiences.

Pilot study of a condensed communication skills workshop for gynecologic oncology fellows.

In gynecologic oncology (GO) fellowship, devoting sufficient time to learning communication skills can be challenging due to required time and logistics. A two day workshop was previously piloted at a single institution with GOs and found to be beneficial. We sought to implement that curriculum in a condensed form. We conducted two four-hour sessions with 4 GO fellows at a single institution over 4 months. Sessions consisted of a didactic in communication skills led by faculty with VitalTalk™ training, followed by application with a simulated patient. Cases were developed and previously used in a two-day workshop at another institution. Fellows were surveyed prior to both sessions and after the second session. Perceived confidence was assessed on a Likert scale (1 to 5). An improvement was defined by an increase of ≥1 in Likert score. All fellows reported that the educational quality of the sessions was "excellent," that the time in between sessions was "just right," allowing them to apply skills learned in the first session prior to the second. After both sessions, at least three of the four fellows reported an improvement in confidence in nearly 50% (10/21) of the communication topics assessed. GO fellows perceived improvements in communication skills with condensed half-day training seminars.

Gynecologic oncology providers endorse practice-changing impact of communication skills training.

OBJECTIVE: Effective communication improves patient outcomes and is crucial to good patient care. Communication skills training (CST) has been shown to improve communication skills in non-gynecologic oncology specialties. We sought to develop and test CST for gynecologic oncology (GO) providers. METHODS: We developed and conducted a two-day CST workshop with an interprofessional group of 20 GO providers over two years. Participants were surveyed pre-workshop, immediately post-workshop and one month post-workshop regarding self-assessed preparedness to handle challenging communication tasks, workshop evaluation and impact on practice. McNemar's tests were used for pre-post comparisons. RESULTS: Of 12 challenging communication tasks assessed, all participants reported improvement in at least one, with a median of 10. The proportion of participants feeling more than "somewhat prepared" improved significantly for all communication tasks assessed (p < 0.05); improvement was sustained one month later. One month post-workshop, 86% reported thinking about what they had been taught at least weekly and 93% reported encountering situations where they used their CST skills at least weekly. Rates of reported practice-changing impact were >75% for each communication skill. All participants rated the CST educational quality very good or excellent and strongly agreed it should be required of all GO clinicians. CONCLUSIONS: Participants felt the workshop provided high-quality, practice-changing education. As a result of the workshop, participants reported statistically significant, sustained improvement in preparedness to handle challenging communication tasks. CST for GO providers is feasible, with high rates of perceived effectiveness and impact on clinical practice. CST workshops should be integrated into GO training.

Resurgence of Eating Disorders with Olanzapine.

BACKGROUND: Olanzapine is commonly utilized in palliative care for the treatment of nausea, and a known side effect of olanzapine is increased appetite. Olanzapine is also known to cause re-emergence of eating disorders (EDs) in patients utilizing olanzapine for its antipsychotic effects. It is unclear to what extent this may also occur in patients with serious/life-limiting illness. METHODS AND RESULTS: We present a case of a 70-year-old female with recurrent ovarian cancer and a history of bulimia nervosa (BN) that developed resurgence of her BN after initiation of olanzapine for cancer-associated nausea. Her BN resolved with reducing the dose of olanzapine. CONCLUSION: It is important to recognize that recurrence of EDs can occur when using olanzapine in the palliative care setting.

End-of-Life Care for Seriously Ill International Patients at a Global Destination Medical Center.

OBJECTIVE: To characterize the end-of-life care of all international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. PATIENTS AND METHODS: We performed a retrospective review of all adult international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. RESULTS: Eighty-two international patients from 25 countries and 5 continents died during the study period (median age, 59.5 years; 59% male). Of the study cohort, 11% (n=9) completed an advance directive, 61% (n=50) died in the intensive care unit, 26% (n=21) had a full code order at the time of death, and 73% (n=19 of 26) receiving cardiopulmonary resuscitation did not survive the resuscitation process. CONCLUSION: Seriously ill international patients who travel to receive health care in the United States face many barriers to receiving high-quality end-of-life care. Seriously ill international patients are coming to the United States in increasing numbers, and little is known about their end-of-life care. There are many unique needs in the care of this complex patient population, and further research is needed to understand how to provide high-quality end-of-life care to these patients.

Palliative Care Competencies and Readiness for Independent Practice: A Report on the American Academy of Hospice and Palliative Medicine Review of the U.S. Medical Licensing Step Examinations.

CONTEXT: It is unknown whether the palliative care (PC) content tested in the U.S. Medical Licensing Examination (USMLE) step examinations reflects the consensus-developed PC competencies. OBJECTIVES: To review the USMLE step examinations to determine whether they test the PC knowledge necessary for graduating medical students and residents applying for licensure. METHODS: Eight PC physicians reviewed three complete examination forms and a focused 509-item bundle of multiple-choice questions (MCQs) identified by the USMLE content outline as potentially assessing PC content. Reviewers determined MCQs to be PC items if the patient was seriously ill and PC knowledge was required to answer correctly. PC items' competency domains were determined using reference domains from PC subspecialty consensus competencies. RESULTS: Reviewers analyzed 1090 MCQs and identified 242 (22%) as PC items. PC items were identified in each step examination. Patients in PC items were mostly males (62.8%), older than 65 years (62%), and diagnosed with cancer (43.6%). Only 6.6% and 6.2%, respectively, had end-stage heart disease or multimorbid illness. Fifty-one percent of PC items addressed ethics (31%) or communication (19.8%), focusing on patient autonomy, surrogate decision makers, or conflict between decision makers. Pain and symptom management was assessed in 28.5% of PC items, and one-third of those addressed addiction or substance use disorder. CONCLUSION: We identified PC content in each step examination. However, heart disease and multimorbidity were under-represented in PC items relative to their prevalence. In addition, there was heavy overlap with ethics, a focus on conflict in assessing communication skills, and emphasis on addiction when testing pain management. Our findings highlight opportunities to enhance testing of clinical PC skills essential for all licensed physicians practicing medicine.

The Experience of Hospital Death: Assessing the Quality of Care at an Academic Medical Center.

BACKGROUND: The quality of perimortem care received by patients who died at our hospitals was unknown. OBJECTIVE: To describe the quality of hospital care experienced in the last week of life, as perceived by decedents' families. DESIGN: Telephone survey that included established measures and investigator-developed content. SETTING: Large, tertiary care center known for high-quality, cost-effective care. PARTICIPANTS: Family members of 104 patients who died in-hospital (10% of annual deaths) over the course of 1 year. INTERVENTION: None. MEASUREMENTS: Participant perceptions of the decedent's care, including symptom management, personal care, communication, and care coordination. RESULTS: Decedents were mostly male (64%), white (96%), married (73%), and Christian (91%). Most survey participants were spouses of the decedent (68%); they were predominately white (98%), female (70%), and Christian (90%) and had a median age of 70 years (range, 35-91 years). Overall satisfaction was high. Pain, dyspnea, and anxiety or sadness were highly prevalent among decedents (73%, 73%, and 55%, respectively) but largely well managed. Most participants believed that decedents were treated respectfully and kindly by staff (87%) and that sufficient help was available to assist with medications and dressing changes (97%). Opportunities for improvement included management of decedents' anxiety or sadness (29%) and personal care (25%), emotional support of the family (57%), communication regarding decedents' illness (29%), and receiving contradictory or confusing information (33%). CONCLUSION: Despite high satisfaction with care overall, we identified important unmet needs. Addressing these gaps will improve the care of dying patients.

Nonpharmacologic approach to fatigue in patients with cancer.

Cancer-related fatigue is a common yet underappreciated problem with a significant impact on functional ability and quality of life. Practice guidelines mandate that all cancer patients and survivors be screened for cancer-related fatigue (CRF) at regular intervals. Comorbidities that could contribute to fatigue should be treated, and patients with moderate to severe fatigue should undergo a comprehensive evaluation. Nonpharmacologic interventions are important tools to combat CRF and should be incorporated into routine practice. Physical activity, educational interventions, and cognitive-behavioral therapy have the most supportive data and can be recommended to patients with confidence. From a practical standpoint, general education on CRF is something that most care providers can readily offer patients as part of routine care. Other interventions that appear promising but are as yet lacking convincing evidence include mindfulness-based stress reduction, yoga, and acupuncture. Reiki, Qigong, hypnosis, and music therapy may be worthy of further investigation.

Nonpharmacologic approach to sleep disorders.

Sleep disturbances are common in patients with cancer, occurring throughout the disease trajectory and sometimes well after treatment has concluded. Insomnia often does not occur in isolation; it may be associated with pain, fatigue, depression, and medication usage. Screening for sleep disturbances is an essential part of caring for oncologic patients. The criterion standard for nonpharmacologic treatment of insomnia in these patients is cognitive-behavioral therapy, a multimodal approach using sleep hygiene and education, stimulus control, sleep restriction, and relaxation. Exercise and complementary and integrative medicine have been studied with varying results, and no firm recommendation can be made about their efficacy.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

PURPOSE: Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. METHOD: Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. RESULTS: The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. CONCLUSIONS: This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

Top 10 things palliative care clinicians wished everyone knew about palliative care.

With a focus on improving quality of life for patients, palliative care is a rapidly growing medical subspecialty focusing on the care of patients with serious illness. Basic symptom management, discussions of prognostic understanding, and eliciting treatment goals are essential pieces in the practice of nearly all physicians. Nonetheless, many complex patients with a serious, life-threatening illness benefit from consultation with palliative care specialists, who are trained and experienced in complex symptom management and challenging communication interactions, including medical decision making and aligning goals of care. This article discusses the changing role of modern palliative care, addresses common misconceptions, and presents an argument for early integration of palliative care in the treatment of patients dealing with serious illness.

Palliative care consultations in patients with cancer: a mayo clinic 5-year review.

PURPOSE: We sought to characterize the aggregate features and survival of patients who receive inpatient palliative care consultation, particularly focusing on patients with cancer, to identify opportunities to improve clinical outcomes. METHODS: We reviewed prospectively collected data on patients seen by the Palliative Care Inpatient Consult Service at Mayo Clinic (Rochester, MN) from January 2003 to September 2008. Demographics, consultation characteristics, and survival were analyzed using Kaplan-Meier survival curves and Cox survival models. RESULTS: Cancer was the most common primary diagnosis (47%) in the 1,794 patients seen over the 5-year period. A significant growth in the annual number of palliative care consultations has been observed (113 in 2003 v 414 in 2007), despite stable total hospital admissions. Frequently encountered reasons for consultation included clarification of care goals (29%), assistance with dismissal planning (19%), and pain control (17%). Although patients with cancer had the highest median survival after consultation in this cohort versus patients with other diagnoses, we observed a 5-year trend of decreasing survival from admission to death and from consultation to death. Median time from admission to death for patients with cancer was 36 days in 2003 and only 19 days in 2008 (P < .01). Median time from consultation to death decreased from 33 days in 2003 to only 11.5 days in 2008 (P < .01). CONCLUSION: Patients with cancer often have complex needs that must be met within a short window for intervention. We highlight opportunities for improved multidisciplinary care for patients with advanced cancer and their families, including opportunity for earlier palliative care involvement, even in the outpatient setting.

Understanding and finding mentorship: a review for junior faculty.

BACKGROUND: Mentorship is considered central to physician success, and yet relatively few physicians report having formal mentors. Ever-increasing demands on physician time as well as multiple personal and professional responsibilities, make it challenging to find and sustain mentoring relationships. These challenges may be even greater in palliative medicine, a field with few mid-level to senior faculty and in which the supply of physicians is inadequate to meet the anticipated demand. DISCUSSION: In this article, we describe the attributes of the "ideal" mentor and the roles mentors commonly play in a protégé's career. We then discuss a framework for optimizing one's chance of fostering mentoring relationships. We conclude by discussing the evolution of and transitions in mentoring relationships, as well as how one might transition from protégé to mentor.

Discussing prognosis: balancing hope and realism.

"How much time do I have?" A patient's question about his/her life expectancy is among the most difficult of conversation topics. Oncologists, often with very little training in communication, routinely handle these requests for sensitive information. Oncologists are aware of the emotional weight surrounding a prognosis discussion: answering a prognosis question poorly can damage both a patient's sense of hope and the relationship with his/her physician. Conversely, when handled well, the discussion can affirm the relationship, build trust, and leave the patient feeling hopeful. Our review presents clinicians with a practical approach to handling prognosis discussions by dealing with 4 critical issues. First, we review what information should be conveyed about a patient's prognosis. Next, we provide tools to help the oncologist deal with a patient's emotional reaction. Then, we provide a framework for the discussion that helps preserve a patient's hope despite a poor prognosis. Finally, we address the impact on the physician and provide some suggestions for dealing with our own emotional reactions.

Sitting with you in your suffering: lessons about intractable pain at the end of life.

This paper describes a case of a hospice patient that a hospice and palliative care team struggled to palliate. We review a case of a 63-year-old man with anal squamous cell carcinoma who was transferred from an inpatient hospice unit to an intensive care setting in an ill-fated attempt to alleviate his pain and suffering. This paper also describes the frustration and desperation on the part of his medical and interdisciplinary team to provide him adequate relief. In retrospect, there were likely many system factors that may have contributed to this patient's ongoing suffering, including restrictions on the use of certain medications by location (i.e., hospice unit versus intensive care setting) as well as medication and ordering misunderstandings. Opiate neurotoxicity, existential and spiritual angst, and social isolation also contributed substantially to this patient's suffering. Furthermore, we describe not only the importance of exhausting all medical resources to relieve patients' pain and suffering, but also of learning to sit with patients in their suffering.