Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents?

BACKGROUND: Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers. METHODS: We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation. RESULTS: Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently. CONCLUSIONS: IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

The Impact of COVID-19 Surge on Clinical Palliative Care: A Descriptive Study From a New York Hospital System.

CONTEXT: In spring 2020, New York experienced a surge of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) disease, as part of a global pandemic. There are limited data on populations of COVID-19-infected patients seen by palliative care services. OBJECTIVE: To describe a palliative care population at one New York hospital system during the initial pandemic surge. METHODS: This repeated cross-sectional, observational study collected data on palliative care patients in a large health system seen during the COVID-19 outbreak and compared it with pre-COVID data. RESULTS: Palliative service volume surged from 678 (4% of total admissions) before COVID-19 to 1071 (10% of total admissions) during the COVID-19 outbreak. During the outbreak, 695 (64.9%) of the total palliative patients tested positive for the virus. Compared with a preoutbreak group, this COVID-19-positive group had higher rates of male (60.7% vs. 48.6%, P < 0.01) and Latino (21.3% vs. 13.3%; P < 0.01) patients and less white patients (21.3% vs. 13.3%; P < 0.01). Our patients with COVID-19 also had greater prevalence of obesity and diabetes and lower rates of end-stage organ disease and cancers. The COVID-19-positive group had a higher rate of intensive care unit admissions (58.9% vs. 33.9%; P < 0.01) and in-hospital mortality rate (57.4% vs. 13.1%; P < 0.01) than the preoutbreak group. There was increased odds of mortality in palliative care patients who were COVID-19 positive (odds ratio = 3.21; 95% confidence interval = 2.43-4.24) and those admitted to the intensive care unit (odds ratio = 1.45; 95% confidence interval = 1.11-1.9). CONCLUSION: During the initial surge of the COVID-19 pandemic in New York, palliative care services experienced a large surge of patients who tended to be healthier at baseline and more acutely ill at the time of admission than pre-COVID-19 palliative patients.

Early Palliative Care for Patients With Brain Metastases Decreases Inpatient Admissions and Need for Imaging Studies.

BACKGROUND: Early encounters with palliative care (PC) can influence health-care utilization, clinical outcome, and cost. AIM: To study the effect of timing of PC encounters on brain metastasis patients at an academic medical center. SETTING/PARTICIPANTS: All patients diagnosed with brain metastases from January 2013 to August 2015 at a single institution with inpatient and/or outpatient PC records available for review (N = 145). DESIGN: Early PC was defined as having a PC encounter within 8 weeks of diagnosis with brain metastases; late PC was defined as having PC after 8 weeks of diagnosis. Propensity score matched cohorts of early (n = 46) and late (n = 46) PC patients were compared to control for differences in age, gender, and Karnofsky Performance Status (KPS) at diagnosis. Details of the palliative encounter, patient outcomes, and health-care utilization were collected. RESULTS: Early PC versus late PC patients had no differences in baseline KPS, age, or gender. Early PC patients had significantly fewer number of inpatient visits per patient (1.5 vs 2.9; P = .004), emergency department visits (1.2 vs 2.1; P = .006), positron emission tomography/computed tomography studies (1.2 vs 2.7, P = .005), magnetic resonance imaging scans (5.8 vs 8.1; P = .03), and radiosurgery procedures (0.6 vs 1.3; P < .001). There were no differences in overall survival (median 8.2 vs 11.2 months; P = .2). Following inpatient admissions, early PC patients were more likely to be discharged home (59% vs 35%; P = .04). CONCLUSIONS: Timely PC consultations are advisable in this patient population and can reduce health-care utilization.

Defending patient autonomy: the case of the challenging spouse.

A case of a 61-year-old patient with advancing cancer is presented. His care was confounded by his wife challenging the care being delivered. The case report is followed by commentaries on the case from three scholarly perspectives, medicine, philosophy, and law.