Voluntary Stopping Eating and Drinking.

Voluntary stopping of eating and drinking (VSED) is a deliberate, self-initiated attempt to hasten death in the setting of suffering refractory to optimal palliative interventions or prolonged dying that a person finds intolerable. Individuals who consider VSED tend to be older, have a serious but not always imminently terminal illness, place a high value on independence, and have significant illness burden. VSED can theoretically be performed independent of clinician assistance and therefore avoids many of the ethical and legal concerns associated with physician-assisted dying or other palliative measures of last resort, However, VSED is an intense process fraught with new sources of somatic and emotional suffering for individuals and their caregivers, so VSED is best supervised by an experienced, well-informed clinician who can provide appropriate pre-intervention assessment, anticipatory guidance, medical treatment of symptoms, and emotional support. Before initiation of VSED, clinicians should carefully screen for inadequately treated psychiatric conditions, unaddressed symptoms, existential suffering, and evidence of coercion-consultation from palliative medicine, psychiatry, or ethics is often indicated. The most common symptoms encountered after starting VSED are extreme thirst, hunger, dysuria, progressive disability, delirium, and somnolence. Although physiologically similar to cessation of artificial nutrition and hydration, the onset and management of symptoms is often different. We propose an organized system for evaluating individual appropriateness for VSED, anticipatory guidance, and management of symptoms associated with VSED. A brief review of ethical and legal considerations follows.

Staff Experiences Forming and Sustaining Palliative Care Teams in Nursing Homes.

Background and Objectives: Building palliative care (PC) capacity in nursing homes (NH) is a national priority and essential to providing high quality care for residents with advanced illness. We report on NH staff experiences in developing and sustaining Palliative Care Teams (PCTeams) as part of a randomized clinical trial to "Improve Palliative Care through Teamwork" (IMPACTT). Research Design and Methods: We conducted rapid ethnographic assessments of all NH (N = 14) in the intervention arm. Data included semistructured interviews with direct care and administrative staff (n = 41), field observations, and written materials. We used a phased approach to data analysis including open coding and comparative analyses within and across homes. Results: We found four key structural themes in our analysis including: administrative support, financial considerations, turnover and staffing, and competing priorities. The development and sustainability of the nascent PCTeams were constantly threatened by competing priorities and the key factor in their success was consistent and tangible administrative support. Discussion and Implications: While improving PC in NHs is a recognized priority, lack of stable infrastructure and unintended consequences of reimbursement policies created conditions which often thwarted the sustainability of the PCTeams.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial.

BACKGROUND: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE: Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Palliative Care, Ethics, and the Law in the Intensive Care Unit.

Over the course of the last half-century, intensive care units have been the setting for many ethical and legal debates in medicine. This article outlines 3 important domains that lie at the intersection of critical care, palliative care, ethics, and the law: withholding and withdrawal of potentially life-sustaining therapies, making decisions for critically ill patients who lack decision-making capacity, and approaching cases of perceived futility when patients and families still request everything that is medically possible. Important principles and precedents that underlie our understanding of how nurses should approach critically ill patients are reviewed.

Opportunities for psychologists in palliative care: Working with patients and families across the disease continuum.

Interdisciplinary palliative care services have been rapidly expanding in health care settings over the past 10 years, particularly through the establishment of interdisciplinary palliative care teams. Relatively few of these teams formally include psychologists, although their skills of enhancing patients' and families' well-being and lessening suffering make an enormous contribution to the care provided. In this article, we define palliative care in broad terms, distinguishing it from hospice and end-of-life care. Using a case-based approach, we then explore the contribution of psychologists to the patient- and family-centered approach espoused by palliative care, including the knowledge, skills, and self-awareness needed to work effectively with these very ill patients and their families. We close with a call to action to better train and integrate psychologists into the rapidly growing field of palliative care.

Palliative use of noninvasive ventilation: navigating murky waters.

BACKGROUND: The use of noninvasive positive pressure ventilation (NPPV) as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NPPV has a well-established, evidence-based role in the management of respiratory failure due to acute exacerbations of congestive heart failure and chronic obstructive pulmonary disease, both for patients with and without restrictions on endotracheal intubation. There are emerging uses of NPPV in patients clearly nearing the end-of-life, but the evidence to support these applications is limited. Alongside these emerging applications of NPPV are new ethical dilemmas that should be considered in medical decision-making regarding these therapies. DISCUSSION: Herein, we describe the use of NPPV in four patients with advanced disease and preexisting treatment-limiting directives. We discuss some of the ethical dilemmas and unintended consequences that may accompany the use of NPPV in such circumstances, and we review the benefits and burdens of palliative NPPV. CONCLUSION: Finally, we conclude with a summary of principles that can be used as a guide to decision making regarding palliative NPPV.

Palliative care communication: linking patients' prognoses, values, and goals of care.

Prognostic communication is a primary component of goals of care conversations in palliative care (PC) practice. Little is known about these conversations in the natural setting. This study's aim was to describe the processes of prognostic communication in PC goals of care consultations. Using line-by-line qualitative analysis, we examined prognostic conversation in 66 audio-taped PC consultations. We identified five processes by which clinicians link prognoses, values, and goals of care: (1) signposting the crossroads; (2) closing off a goal; (3) clarifying current path; (4) linking paths and patients' values; and (5) choosing among paths. The findings add to our understanding of PC consultation by describing how prognoses link with patients' values and choices in goals of care conversations.

Physicians should "assist in suicide" when it is appropriate.

Palliative care and hospice should be the standards of care for all terminally ill patients. The first place for clinicians to go when responding to a request for assisted death is to ensure the adequacy of palliative interventions. Although such interventions are generally effective, a small percentage of patients will suffer intolerably despite receiving state-of-the-art palliative care, and a few of these patients will request a physician-assisted death. Five potential "last resort" interventions are available under these circumstances: (1) accelerating opioids for pain or dyspnea; (2) stopping potentially life-prolonging therapies; (3) voluntarily stopping eating and drinking; (4) palliative sedation (potentially to unconsciousness); and (5) physician-assisted death. Patient, family, and clinicians should search for the least harmful way to respond to intolerable end-of-life suffering in ways that are effective and also respect the values of the major participants. A system that allows an open response to such cases ultimately protects patients by ensuring a full clinical evaluation and search for alternative responses, while reinforcing the need to be responsive and to not abandon.

Navigating tensions: integrating palliative care consultation services into an academic medical center setting.

CONTEXT: Despite rapid proliferation of hospital-based palliative care consultation services (PCCSs) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS. OBJECTIVES: To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service. METHODS: Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care AMC in the northeastern region of the U.S. Participants were a purposefully selected sample (n=79) of 1) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, 2) clinicians who used the PCCS, either commonly or rarely, and 3) members of the PCCS core and extended teams. RESULTS: Key infrastructure components that contributed to the successful integration of the PCCS included top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the "physician referral only" rule, and incremental and sustainable growth. The PCCS service grew an average of 23% per year from 2003 to 2009. CONCLUSION: An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.

Palliative care needs and symptom patterns of hospitalized elders referred for consultation.

CONTEXT: To provide effective palliative care (PC) to the geriatric population, an understanding of the reasons for consultation, main diagnoses related to referral, and symptom severity in chronic disease states is essential. OBJECTIVES: We compared the baseline characteristics, referral patterns, and symptom severity among older and younger patients referred for inpatient PC consultation. METHODS: We conducted a retrospective review of 2382 inpatient PC consultations. We excluded "reconsultations" and patients under the age of 18. Patient characteristics (reason for consultation and diagnosis) and symptom severity were compared across three age groups: Younger, <65 years of age; Older, 65-84 years of age; and Oldest, 85 years of age and older. Multivariable logistic regression adjusted for the effects of gender, ethnicity, and diagnostic subset was performed. RESULTS: Most patients referred for inpatient PC consultation were older than the age of 65. Oldest patients were consulted on earlier and more often for "end-of-life care." Oldest adults were less likely to report pain, anxiety, and nausea (adjusted odds ratios [AOR] of 0.25, 0.39, and 0.19, respectively) and more likely to report anorexia than Younger adults (AOR=1.66). There was no clear difference between age groups in reporting of dyspnea and depression. CONCLUSION: Older adults in need of PC appear to have symptom burdens and consultation referral patterns that are different from those of younger patients. Further research is needed to determine whether these symptom patterns are caused by psychosocial factors, whether these reflect true differences among age groups, and whether symptom measurement instruments should be tailored to patient age.

Palliative care consultations in hospitalized stroke patients.

OBJECTIVE: To determine the pattern and characteristics of palliative care (PC) consultations in patients with stroke and compare them with the characteristics of nonstroke consultations. METHODS: The palliative care program at Strong Memorial Hospital (SMH) was established in October 2001. SMH is a 765-bed academic medical center with approximately 38,000 discharges. For each consult from 2005 to 2007, we collected demographic, clinical, and service-related information. We explored similarities and differences in patients with different types of stroke, including patients with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hematoma. In addition, we compared these data to the nonstroke patients who had a palliative care consultation during the same time period. RESULTS: Over the 3-year period from 2005 to 2007, there were a total of 101 consultations in patients with stroke (6.3% of all PC consultations). Of the 101 consultations, 31 were in patients with ischemic stroke, 26 in patients with intracerebral hemorrhage, 30 in patients with subarachnoid hemorrhage, and 14 in patients with subdural hematoma. Patients with stroke who had a PC consult were more functionally impaired, less likely to have capacity, more likely to die in the hospital, and to have fewer traditional symptom burdens than other common diagnoses seen on the PC consultation service. The most common trajectory to death was withdrawal of mechanical ventilation, but varied by type of stroke. Common treatments negotiated in these consultations included mechanical ventilation, artificial nutrition, tracheostomy, and less likely antibiobics, intravenous fluids, and various neurosurgical procedures. CONCLUSIONS: Patients with stroke are a common diagnosis seen on an inpatient palliative care consult service. Each stroke type represents patients with potentially distinct palliative care needs.