Evaluation of Peak Inspiratory Flow Rate in Hospitalized Palliative Care Patients with COPD.

Dry powder inhalers are an effective yet costly COPD medication-delivery device. Patients must possess a minimum peak inspiratory flow rate (PIFR) for inhaled medication to be properly deposited into the lungs. Hospitalized palliative-care patients with diminished lung function due to advanced COPD may not possess the minimum PIFR (30 L/min) for adequate drug delivery. This study aims to quantify PIFR values for hospitalized palliative-care patients with advanced COPD to evaluate whether these patients meet the minimum PIFR requirements. Hospitalized patients ≥18 years old with a palliative-care consultation were eligible if they had a diagnosis of advanced COPD (GOLD C or D). Patients were excluded if they lacked decision-making capacity or had a positive COVID-19 test within the previous 90 days. Three PIFR values were recorded utilizing the In-CheckTM device, with the highest of the three PIFR attempts being utilized for statistical analysis. Eighteen patients were enrolled, and the mean of the highest PIFR readings was 72.5 L/min (±29 L/min). Post hoc analysis indicated 99.9% power when comparing the average best PIFR to the minimum PIFR (30 L/min) but only 51.4% power when compared to the optimal PIFR (60 L/min). This study found that palliative-care patients possess the minimum PIFR for DPI drug delivery.

SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention.

BACKGROUND: Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM: Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION: SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES: Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED: Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

SHARING Choices: Design and rationale for a pragmatic trial of an advance care planning intervention for older adults with and without dementia in primary care.

BACKGROUND: Advance care planning (ACP) and involving family are particularly important in dementia, and primary care is a key setting. The purpose of this trial is to examine the impact and implementation of SHARING Choices, an intervention to improve communication for older adults with and without dementia through proactively supporting ACP and family engagement in primary care. METHODS: We cluster-randomized 55 diverse primary care practices across two health systems to the intervention or usual care. SHARING Choices is a multicomponent intervention that aims to improve communication through patient and family engagement in ACP, agenda setting, and shared access to the patient portal for all patients over 65 years of age. The primary outcomes include documentation of an advance directive or medical orders for life-sustaining treatment in the electronic health record (EHR) at 12 months for all patients and receipt of potentially burdensome care within 6 months of death for the subgroup of patients with serious illness. We plan a priori sub-analysis for patients with dementia. Data sources include the health system EHRs and the Maryland health information exchange. We use a mixed-methods approach to evaluate uptake, fidelity and adaptation of the intervention and implementation facilitators and barriers. CONCLUSIONS: This cluster-randomized pragmatic trial examines ACP with a focus on the key population of those with dementia, implementation in diverse settings and innovative approaches to trial design and outcome abstraction. Mixed-methods approaches enable understanding of intervention delivery and facilitators and barriers to implementation in rapidly changing health care systems. CLINICALTRIALS: gov Identifier: NCT04819191.

Deprescribing Interventions by Palliative Care Clinical Pharmacists Surrounding Goals of Care Discussions.

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Interprofessional Healthcare Students' Attitudes, Skills, and Knowledge After Comprehensive Pain Assessment Training in Verbal and Nonverbal Patients.

A comprehensive pain assessment is the first step in safe, effective pain management. Few studies have explored variations of strategies and measures for multidimensional pain assessment education in both verbal and nonverbal patients. In this retrospective cohort study, interprofessional health care students enrolled in a palliative care curriculum completed a pain assessment training, which taught the PQRSTA ("palliating factors, precipitating factors, previous treatments, quality, region, radiation, severity, temporal factors and associated symptoms") mnemonic as a strategy for assessing pain in verbal patients and the Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures for nonverbal patients. The purpose of this study was to compare the change in attitudes, self-perceived skills, and knowledge regarding pain assessment before and after the training. Attitudes and self-perceived skills were assessed in the pretraining and posttraining survey, which was analyzed using χ2 test or Fisher exact test. Students' knowledge responses were analyzed using Wilcoxon signed rank test to assess accuracy of responses compared with the expert defined score. One hundred eighty-two students were included. Results showed a statistically significant improvement in attitudes related to applicability of pain measures and self-perceived skills. Overall, data did not support an increase in knowledge using the PQRSTA mnemonic, or Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures. Future pain trainings should consider training on only 1 nonverbal pain measure, incorporating bedside assessments, and integrating real-time feedback.

Getting to the Heart of the Matter: A Regional Survey of Current Hospice Practices Caring for Patients With Heart Failure Receiving Advanced Therapies.

BACKGROUND:: No guidelines exist regarding care for patients with advanced heart failure (HF) receiving hospice care while continuing advanced HF therapies such as left ventricular assist devices (LVADs) or continuous inotropes. OBJECTIVE:: We surveyed hospice providers in our tristate region to determine hospice demographics, current practices for care of patients with advanced HF, and perceived challenges of providing advanced HF therapies. DESIGN:: Cross-sectional survey of hospice clinical and administrative leaders. RESULTS:: Forty-six respondents representing 23 hospices completed the survey. Over half (27/46) held leadership administrative roles, and most (37/46) had more than 5 years of hospice experience. Although lack of experience and cost were cited as primary barriers to providing inotrope therapy in home hospice, about half of respondents (24/46) said they would manage inotropes. All participants said their respective hospices accept patients with implantable cardioverter-defibrillators; over half (28/46) said they accept patients with LVADs into hospice care. Lack of experience with LVADs was the most frequently cited barrier. Most participants were interested in training and support by an advanced HF program to facilitate hospice care of patients receiving these advanced therapies. General access to hospice services for patients with HF at their organization was considered adequate by 30 of 46 participants. Most (32/46) reported that referrals are made too late. CONCLUSIONS:: Hospice specialists reported widely varied practice experiences caring for patients with HF receiving advanced therapies, noted specific challenges for care of these patients, and expressed a desire for targeted HF education.

Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper.

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.

State survey of medical boards regarding abrupt loss of a prescriber of controlled substances.

OBJECTIVES: The purpose of the study was to evaluate states' experiences with abrupt changes in controlled substances (CS) prescribing, to determine whether states have action plans in place to manage such situations, and describe the components of any such plans. METHODS: A survey of executive directors of 51 medical boards was conducted to evaluate states' experiences with abrupt changes in CS prescribing, the extent of consumer complaints attributed to these events, and the types of plans in place to manage these situations. RESULTS: Forty-six executive directors of medical boards responded. Twenty boards (43.5 percent) confirmed that their state had experienced abrupt loss of CS providers and 11 (55 percent) of these executive directors indicated that the loss resulted in increased consumer complaints. The majority of executive directors (86 percent) had no action plan. Six executive directors reported some type of action plan or process consisting of regulatory action, patient-provider connection, professional education, patient education, or public notice. CONCLUSIONS: Most states do not have operational plans in place. However, a few have key strategies that may be useful in addressing potential problems following abrupt loss of a CS prescriber. State medical boards can play a significant role in the development of comprehensive preparedness plans to mitigate damage from the loss of CS prescribers in the community.

Effectiveness of integration of palliative medicine specialist services into the intensive care unit of a community teaching hospital.

BACKGROUND: Collaboration between palliative medicine and the intensive care unit (ICU) represents best practice and offers important benefits. However, achieving effective collaboration between these two specialties can be challenging. OBJECTIVE: Assess effectiveness of integrating palliative medicine specialists in the ICU. DESIGN: Retrospective chart review. RESULTS: Of 201 patients who qualified for palliative consultation using a palliative screening tool, 92 were referred and 109 were not referred for palliative medicine consultation. The number of screening criteria met was similar between the two groups. Palliative medicine consult volume increased significantly compared with preintegration (7.7±3.4 versus 4.4±2.8 consults per month, p=0.04). No significant difference in hospital mortality was found between the referred and unreferred groups (32/92 [35%] versus 26/109 [24%], p=0.09). ICU length of stay was significantly shorter in the referred group (7 versus 11 days, p<0.001). Referred patients were more frequently enrolled in hospice compared with unreferred patients (32/92 [37%] versus 3/109 [3%], p<0.001). ICU physicians referred patients significantly more often for dementia and ventilator withdrawal (13/16, p=0.003; 24/29, p<0.001, respectively) and significantly less often for ICU stay longer than 10 days (21 versus 49, p=0.001). CONCLUSIONS: Integrating palliative medicine specialists into intensive care was associated with a significant increase in use of palliative medicine services and a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. The screening tool effectively identified patients at high risk of death. Given the high mortality rate of the unreferred patients, the criteria could be more widely adopted by ICU physicians to consider expanding palliative medicine referrals.

50 practical medication tips at end of life.

Patients with a life-limiting illness frequently experience pain and other symptoms. It is important to pay close attention when medication therapy is used to manage these symptoms. Occasionally, practitioners need to be creative in selecting, dosing, administering, and discontinuing medications at the end of life because of the patient's changing health care needs. This article offers practical end-of-life medication tips including, but not limited to, medication administration; guidance on how to increase and decrease doses; medication selection for difficult-to-treat patients; alternative dosage formulations; routes of medication administration; debridement medication regimens; and appropriate drug therapy selection.

A review of common methods to convert morphine to methadone.

When dosed appropriately on carefully chosen patients, methadone can be a very safe and effective choice in managing chronic pain. Many authors have discussed important issues surrounding patient selection, drug interactions, screening for QTc prolongation and monitoring. This article will focus on the dosing dilemma that exists after the patient is deemed an appropriate candidate for methadone and a conversion is necessary from another opioid. Despite many publications dedicated to addressing this challenging topic, there is no consensus on the most appropriate method for converting an opioid regimen to methadone. Given the lack of concrete guidance, clinicians in a community setting are likely to be faced with an increased challenge if there are no available pain specialists to provide clinical support. Common methods for converting morphine to methadone will be reviewed and two clinical patient scenarios used to illustrate the outcomes of applying the methods.

Impact of standardized palliative care order set on end-of-life care in a community teaching hospital.

BACKGROUND: We evaluated use of medications and interventions in patients receiving a new standardized palliative care order set (PCOS) compared with patients receiving no palliative care orders and those with an order for comfort measures only (CMO), the largely ineffective method used at our institution before implementation of the order set. METHODS AND RESULTS: We conducted a retrospective chart review of all patients who died at our community teaching hospital between November 2006, 8 months after PCOS implementation, and May 2007. Of 106 patients in the study group, 31 (29%) were treated using the PCOS, 6 (6%) received the CMO order, and 69 (65%) did not receive either. Patients in the PCOS group had significantly more orders for every palliative medication (p ≤ 0.05). Opioids and anxiolytics were made available to every patient in the PCOS group. Most PCOS patients received orders for antiemetic, antipsychotic, antisecretion, and laxative medication during the end-of-life period. No CMO patients and few patients in the no palliative care orders group received orders for these medications. The PCOS and CMO group similarly limited nonpalliative interventions, whereas the nonpalliative group had relatively high use of these interventions until death. CONCLUSION: The palliative care order set implemented at our community teaching hospital significantly improved adherence to accepted palliative care treatment principles for patients at the end of life.

Fifty reasons to love your palliative care pharmacist.

Pharmacists have much to offer in caring for patients with an advanced illness. To celebrate the role of pharmacists in palliative care, we wanted to share 50 excellent reasons to love your pharmacist. This list was compiled by 3 pharmacists specializing in end-of-life care spanning from inpatient palliative care to home-based hospice. Our goal is to increase awareness among other hospice and palliative care practitioners by recognizing the skills pharmacists contribute in caring for patients at the end of life. We divided the list into categories: provision of pharmaceuticals, optimizing medication regimens, education and drug information, patient safety, and administration/formulary management.

Perceived value and cost of providing emergency medication kits to home hospice patients in Maryland.

Many hospices have adopted the use of ''emergency medication kits'' (EMK) to allow for management of emergent symptoms and to prevent unscheduled patient interventions. The purpose of this study was to compare perceptions of hospice managers and clinicians regarding the value of EMK and to assess outcomes. Clinical managers and clinicians reported that EMK were valuable in preventing emergency department visits, unscheduled nursing visits, pharmacy deliveries, and increased satisfaction. A hospice using EMK reported fewer calls requiring unscheduled interventions (18% vs 33%) and resulted in cost savings (US$23.04 per call vs US$31.62 per call). Hospice managers and clinicians perceived EMK to be valuable in areas of quality, cost, and satisfaction. There appears to be an advantage to routinely providing EMK for home hospice patients.

Impact of writing "comfort measures only" orders in a community teaching hospital.

OBJECTIVES: We compared end-of-life care for patients with and without orders for "comfort measures only" (CMO) and evaluated whether standards for palliative medicine were met. DESIGN: We retrospectively reviewed the charts of 40 patients, 20 with and 20 without a CMO order, who died in our community teaching hospital from October 2003 through September 2004. Appropriate use of medications and interventions and documentation of symptoms and family consultation were examined. RESULTS: There were no significant demographic differences between the groups. Family meeting (18/20 versus 7/20, p < 0.001) and do-not-resuscitate/do-not-intubate (DNR/DNI) code status (20/20 versus 8/20; p < 0.001) occurred significantly more frequently in the CMO group. There were no other significant differences in prescribing medications or treatments. Notation of symptoms common at the end of life did not differ between the groups except for nausea/vomiting, which was more common in the non-CMO group. In the CMO group, opioids were significantly more available and antibiotics and routine laboratory work were significantly less common after the CMO order, but no other differences were observed. CONCLUSION: CMO orders alone were insufficient for redirecting changes in care at the end-of-life.