Emergency medicine physicians' perspectives of providing palliative care in an emergency department.

This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

The palliative care model for emergency department patients with advanced illness.

BACKGROUND: Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). DISCUSSION: Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition. CONCLUSION: Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

Perspectives from the other side: a physician and cancer survivor.

ASCO has made great strides to integrate palliative care into the comprehensive care model. However, much work remains to ensure that all patients, whether receiving curative or palliative therapy, have a good quality of life.

The intersection of need and opportunity: assessing and capitalizing on opportunities to expand hospital-based palliative care services.

BACKGROUND: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact. SUBJECTS AND METHODS: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.

Treatment preferences: impact of risk and benefit in decision-making.

Understanding treatment preferences of seriously ill patients is complex. Previous studies have shown a correlation between the burden and outcome of a treatment and the likelihood a patient will accept a given intervention. In this study the Willingness to Accept Life Sustaining Treatment (WALT) survey was used in a predominantly Latino population receiving care at a large urban safety net hospital. Eligible patients were cared for by one of four clinics: (1) human immunodeficiency virus (HIV); (2) geriatrics; (3) oncology; or (4) cardiology. Hypothetical scenarios reflecting outcomes of resuscitation were presented and patients were given information on the burden and outcome of treatment. They were then given the option of accepting or declining treatment; 237 completed the survey. Patients in our study were willing to accept a high level of cognitive (vegetative state) and functional (bed-bound) impairment even when the chance of recovery was exceedingly low.

IFN-gamma is the only anti-rotavirus cytokine found after in vitro stimulation of memory CD4+ T cells from mice immunized with a chimeric VP6 protein.

CD4+ T cells are the only lymphocytes required for protection of mice against rotavirus shedding after mucosal immunization with chimeric VP6 (MBP::VP6) and the adjuvant LT(R192G). One possible effector of protection is CD4+ T-cell cytokines. To determine if memory CD4+ T cells of immunized mice produce cytokines with direct anti-rotavirus activity, an in vitro infection model was developed using mouse CMT-93 cells and rhesus rotavirus (RRV). Spleen and lamina propria (LP) cells, as well as purified splenic CD4T cells obtained after intranasal immunization of BALB/c mice with MBP::VP6/LT(R192G) released large quantities of two cytokines (IL-17 and IFN-gamma) into cell supernatants when stimulated with MBP::VP6. Production of these same cytokines is rapidly upregulated in intestinal lymphocytes after rotavirus inoculation of immunized mice. IL-17 pretreatment of CMT-93 cells had no effect on subsequent RRV replication, but IFN-gamma was the most potent inhibitor within a panel of nine cytokines tested. Supernatants obtained after in vitro stimulation of splenic CD4+ T cells of immunized mice had high levels of anti-RRV activity and their pretreatment with mAb against IFN-gamma caused essentially complete loss of activity. Thus, IFN-gamma was the only cytokine identified in stimulated CD4+ T cells from immunized mice that directly inhibited rotavirus replication.