An Active In-Home Physician Model of Palliative Care and Its Resulting Performance Indicators Related to Home Deaths, Unplanned Emergency Department Visits and Unplanned Hospital Admissions.

BACKGROUND: Limited research has characterized team-based models of home palliative care and the outcomes of patients supported by these care teams. CASE PRESENTATION: A retrospective case series describing care and outcomes of patients managed by the London Home Palliative Care Team between May 1, 2017 and April 1, 2019. CASE MANAGEMENT: The London Home Palliative Care (LHPC) Team care model is based upon 3 pillars: 1) physician visit availability 2) active patient-centered care with strong physician in-home presence and 3) optimal administrative organization. CASE OUTCOMES: In the 18 month study period, 354 patients received care from the London Home Palliative Care Team. Most significantly, 88.4% (n = 313) died in the community or at a designated palliative care unit after prearranged direct transfer; no comparable provincial data is available. 21.2% (n = 75) patients visited an emergency department and 24.6% (n = 87) were admitted to hospital at least once in their final 30 days of life. 280 (79.1%) died in the community. These values are better than comparable provincial estimates of 62.7%, 61.7%, and 24.0%, respectively. CONCLUSION: The London Home Palliative Care (LHPC) Team model appears to favorably impact community death rate, ER visits and unplanned hospital admissions, as compared to accepted provincial data. Studies to determine if this model is reproducible could support palliative care teams achieving similar results.

A Pilot Cross-Discipline Evidence-Based Palliative Care Curriculum for Postgraduate Medical Trainees.

INTRODUCTION: It is widely recognized that physicians of all backgrounds benefit from having a general palliative care skill set to optimally manage their patients at the end of life. However, strategies to teach palliative care skills to trainees outside palliative medicine vary widely. In this report, we provide an evidence-based and cross-disciplinary palliative care framework applicable to a spectrum of specialty training environments and intended for nonpalliative care trainees. INNOVATION: We developed and implemented a concise, multimodal, and evidence-based pilot palliative care curriculum focused on essential general palliative care skills required by physicians providing patient care along the continuum of life across specializations. A needs assessment (local research, literature review, and consensus expert opinion) in combination with learner characteristics (Kolb Learning Style Inventory, Palliative Medicine Comfort and Confidence Survey, and knowledge pretest) informed the development of a curricular outline. The first iteration of the curriculum was formulated and delivered. Extensive evaluation, reassessment, and feedback led to a second iteration, which is presented here. OUTCOMES: Although the context will differ according to specialization, there are essential palliative care skills required of most specialist physicians. General palliative themes identified for focus include symptom management, communication, psychosocial aspects of care, care coordination and access, and myths and pitfalls in palliative care. COMMENT: Specialty trainees' value embedded training in essential themes in palliative care within the context of their training program. The process and results of this project, including the provision of a framework, may be applied to postgraduate training programs in various specialties.

Enhancing Physician Managerial Capabilities: Partnership between Medicine and Business.

This article was migrated. The article was marked as recommended. Background Physicians are typically appointed to leadership roles within health care organizations on the basis of individual accomplishments in research, education, and/or clinical care. However, these types of achievements seldom provide the requisite management capabilities to lead within health organizations. In this manuscript, we described our initial experience in developing an in-house program to provide current and aspiring physician leaders with the managerial capabilities to enhance the quality of health care delivery within their respective organization. Methods In a partnership established between a Medical School and a Business School, we designed two series of weekend workshops to provide current and aspiring physician leaders with the financial capabilities to assist them in their future healthcare leadership careers. This course was then expanded to a Management Principles for Physician workshop with open enrollment to physicians at all levels. Baseline demographics and participant evaluations of each course were recorded. In the open enrollment Management Principles for Physician workshop, we examined the relationship between participant background and their course evaluations as well as their areas of interest for further training. Results All 3 workshops received excellent evaluations by participants. The positive impact of the open enrollment program, based on participants' self-evaluations, was the highest in female physicians, as well as early to mid-career physicians. Additionally, physicians who do not currently hold leadership positions and those who are leading at Divisional levels were the most interested in further training in finance. Conclusion In summary, this series of workshops demonstrated the feasibility of an in-house physician leadership program and yielded important information for the design of future leadership development curriculum.

Single- and Multiple-Dose Pharmacokinetics of Once-Daily Formulations of Raltegravir.

A new once-daily formulation of raltegravir, an integrase strand transfer inhibitor indicated in combination with other antiretroviral drugs for the treatment of human immunodeficiency virus-1 infection, is under development. Single-dose and steady-state pharmacokinetics of 1200 mg for 2 formulations of raltegravir were characterized in 2 open-label phase 1 studies in healthy male and female subjects aged 18 to 55 years. The new raltegravir 600-mg formulation had a higher relative bioavailability compared with the 400-mg tablets. Once absorbed, both 3 × 400-mg and 2 × 600-mg dosage forms of raltegravir exhibited similar systemic pharmacokinetics; in dictating bioavailability, differences were from increased absorption that was the result of improved in vivo disintegration/dissolution. Food had a smaller effect on the pharmacokinetics of raltegravir when given as 2 × 600-mg formulation (42% vs 73% decrease in AUC0-last ). Steady state was generally reached in 2 days, with little to no accumulation with multiple-dose administration. Raltegravir 1200 mg was found to exhibit pharmacokinetic properties amenable for once-daily dosing and was generally well tolerated in healthy subjects after single and multiple doses. The new formulation improved the bioavailability of this Biopharmaceutics Classification System class II compound.

Palliative Medicine-Becoming a Subspecialty of the Royal College of Physicians and Surgeons of Canada.

The discipline of palliative medicine in Canada started in 1975 with the coining of the term "palliative care." Shortly thereafter, the provision of clinical palliative medicine services started, although the education of the discipline lagged behind. In 1993, the Canadian Society of Palliative Care Physicians (CSPCP) started to explore the option of creating an accredited training program in palliative medicine. This article outlines the process by which, over the course of 20 years, palliative medicine training in Canada went from a mission statement of the CSPCP, to a 1 year of added competence jointly accredited by both the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada, to a 2-year subspecialty of the Royal College with access from multiple entry routes and a formalized accrediting examination.

Beyond Simple Planning: Existential Dimensions of Conversations With Patients at Risk of Dying From Heart Failure.

CONTEXT: Despite the recent promotion of communication guides to improve decision making with patients nearing the end of their lives, these conversations remain challenging. Deeper and more comprehensive understanding of communication barriers that undermine discussions and decisions with patients at risk of dying from heart failure (HF) is vital for informing communication in health care. OBJECTIVES: To explore experiences and perspectives of patients with advanced HF, their caregivers, and providers, regarding conversations for patients at risk of dying from HF. METHODS: Following Research Ethics Board approval, index patients with advanced HF (New York Heart Association III or IV) and consenting patient-identified care team members were interviewed. A team sampling unit was formed when the patient plus at least two additional team members participated in interviews. Team members included health professionals (e.g., cardiologist, family physician, HF nurse practitioner, social worker, and specialists, such as respirologist, nephrologist, palliative care physician), family caregivers (e.g., daughter, spouse, roommate, close friend), and community members (e.g., minister, neighbor, regular taxi driver). Our data set included 209 individual interviews clustered into 50 team sampling units at five sites from three Canadian provinces. Key informants, identified as practicing experts in the field, reviewed our initial findings with attention to relevance to practice as a form of triangulation. Iterative data collection and analysis followed constructivist grounded theory procedures with sensitizing concepts drawn from complexity theory. To ensure confidentiality, all participants were given a pseudonym. RESULTS: Participants' reports of their perceptions and experiences of conversations related to death and dying suggested two main dimensions of such conversations: instrumental and existential. Instrumental dimensions included how these conversations were planned and operationalized as well as the triggers and barriers to these discussions. Existential dimensions of these conversations included evasive maneuvers, powerful emotions, and the phenomenon of death without dying. Existential dimensions appeared to have a basis in issues of mortality and could strongly influence conversations related to death and dying. CONCLUSION: Conversations for patients at risk of dying from HF have both instrumental and existential dimensions, in which routines and relationships are inseparable. Our current focus on the instrumental aspects of these conversations is necessary but insufficient. The existential dimensions of conversations related to death are profound and may explain why these conversations have struggled to achieve their desired effect. To improve this communication, we need to also attend to existential dimensions, particularly in terms of their impact on the occurrence of these conversations, the nature of relationships and responses within these conversations, and the fluidity of meaning within these conversations.

'Who is on your health-care team?' Asking individuals with heart failure about care team membership and roles.

BACKGROUND: Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care. OBJECTIVES: To explore how individuals with HF conceptualize their care team, and perceive team members' roles. SETTING AND PARTICIPANTS: Individuals with advanced HF were recruited from five cities in three Canadian provinces. DESIGN: Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis. RESULTS: A total of 62 individuals with HF identified 2-19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management. DISCUSSION: Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses. CONCLUSION: Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens - and collaborating meaningfully among identified team members - may improve health-care delivery.

Supernumerary phantom limbs in ICU patients with acute inflammatory demyelinating polyneuropathy.

OBJECTIVE: To explore the previously undescribed phenomenon of phantom limb generation in patients with severe acute inflammatory demyelinating polyradiculoneuropathy (AIDP). METHODS: Between April 2011 and January 2014, we encountered 3 patients with AIDP in our intensive care unit who experienced features of self-limited supernumerary phantom limbs (SPLs) during their course. RESULTS: The following case series describes the phenomenon of SPLs in AIDP. CONCLUSIONS: This report aims to raise awareness of the possibility of SPLs in the course of AIDP. The pathophysiology and management strategies for this clinical phenomenon are unknown.

Novel Gastroretentive Controlled Release Formulations for Once-Daily Administration: Assessment of Clinical Feasibility and Formulation Concept for Raltegravir.

BACKGROUND: Raltegravir is an integrase strand transfer inhibitor indicated in combination with other anti-retroviral medicinal products for the treatment of HIV-1 infection, given twice daily. Although a BCS class II compound, raltegravir exhibits low colonic absorption, thus making development of modified release formulations challenging. It was hypothesized that a gastroretentive (GR) formulation would increase trough (C24 h) concentrations of raltegravir, hence being amenable to a once-daily (QD) regimen. METHODS: Iterative prototype GR formulations were developed in monolithic, bilayer, and trilayer tablet designs. Four phase I studies in healthy subjects were conducted to provide proof of formulation concept. RESULTS: Raltegravir C24 h was increased by a GR formulation with scintigraphy data supporting gastric retention. Single-dose exposures from a trilayer tablet administered in the morning with a high-fat meal resulted in acceptable C24 h values. However, C24 h values for evening dosing with a high-fat meal did not meet the success criteria for QD administration. Raltegravir C24 h and area under the curve (AUC) values after AM dosing with a low-fat meal were significantly lower than after dosing with a moderate-fat meal. Skipping, delaying, or giving a low-fat, low-calorie lunch after dosing with a high-calorie breakfast also resulted in an unacceptable decline in C24 h values. The requirements for consistent product performance under varying conditions of diet, timing of dosing, and dose were not favorable when given as GR tablets. CONCLUSIONS: The findings from these studies offer valuable insights into modifying the absorption of candidate drugs with limiting colonic permeability and solubility characteristics and the interplay between meal, dose timing, and GR formulation performance.

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.

BACKGROUND: Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease. METHODS: Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory. RESULTS: This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings. CONCLUSION: Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.

Non-obligatory role of prostaglandin D2 receptor subtype 1 in rosacea: laropiprant in comparison to a placebo did not alleviate the symptoms of erythematoelangiectaic rosacea.

Erythematotelangiectatic rosacea shares facial flushing features with those seen after niacin. This study was performed to test the hypothesis whether prostaglandin D2 (PGD2) receptor subtype 1 antagonist (laropiprant) will improve the symptoms of rosacea. The purpose of this study was to evaluate the effect of laropiprant 100 mg administered once daily for 4 weeks on the signs and symptoms of erythematotelangiectatic rosacea. Subjects received laropiprant 100 mg once-daily (n = 30) or placebo (n = 30) for 4 weeks. The primary pharmacodynamics endpoint was change in Clinician's Erythema Assessment (CEA) score from baseline to week 4. The patient self-assessment (PSA) was a secondary endpoint. Laropiprant was generally well tolerated in this study for the primary endpoint of change in CEA score from Baseline to Week 4, the least-squares mean of change from baseline to visit 4/week 4 was -3.7 and -3.4 for placebo and laropiprant (100 mg), respectively. The least-squares mean difference (placebo minus laropiprant) with 90% confidence interval of change in CEA score from baseline to visit 4/week 4 was estimated as -0.3 (-1.6, 1.0). For the secondary endpoint, the least-squares mean difference (placebo minus laropiprant) with 90% confidence interval of change from baseline to visit 4/week 4 was estimated as -0.7 (-7.7, 6.4) for PSA total score, -4.5 (-14.2, 5.3) for PSA emotion score, -1.3 (-7.8, 5.3) for PSA symptoms score, and 3.6 (-4.3, 11.4) for PSA functioning score. Laropiprant administered once daily for 4 weeks was generally well tolerated in this population of subjects with rosacea. However, there were no clinically meaningful changes in the primary endpoint of CEA given that the response to laropiprant could not be differentiated from that to placebo. There was also no clinically meaningful change in the secondary endpoint, PSA. A DP1 antagonist is not likely to be effective in rosacea.

Early-stage comparative effectiveness: randomized controlled trial with histamine inverse agonist MK-7288 in excessive daytime sleepiness patients.

Histaminergic neurons are regulators of the sleep-wake cycle. We evaluated the alerting effects of MK-7288 (10, 20 mg), a novel histamine-3 receptor inverse agonist (H3RIA), along with modafinil (200 mg), a standard treatment, in a randomized, double-blind, placebo controlled, crossover study of 56 patients with excessive daytime sleepiness (EDS). Efficacy was assessed using maintenance of wakefulness tests (MWT) and car driving simulation tests. MK-7288 and modafinil significantly prolonged MWT sleep latency (improvements vs. placebo of 8.1 to 8.2 min for MK-7288 and 10.2 min for modafinil), and improved car driving simulation standard deviation of lane position (reduction vs. placebo of -0.1 m for each treatment). MK-7288 was associated with more insomnia (29%) than modafinil (9%) and placebo (6%). The study demonstrated the potential of the H3RIA mechanism for treating EDS, but did not show efficacy differentiation from modafinil. Early-stage comparative effectiveness can help prevent late-stage failure and increase the cost-effectiveness of drug development.

The distinct role of palliative care in the surgical intensive care unit.

Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. Palliative care enhances the SICU team's ability to recognize pain and distress; establish the patient's wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation. Educational opportunities to improve end-of-life management skills are outlined. It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU. Palliative care can provide a significant, "value added" contribution to the care of seriously ill SICU patients.

Understanding palliative care on the heart failure care team: an innovative research methodology.

CONTEXT: There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES: To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS: This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS: We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION: We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Being a hospice volunteer influenced medical students' comfort with dying and death: a pilot study.

Being comfortable with death and communicating with patients near the end of life are important attributes in palliative care. We developed a hospice volunteer program to teach these attitudes and skills to preclinical medical students. Using a mixed-methods approach, validated surveys measured participants' and non-participants fear of death and communication apprehension regarding dying. Journals and focus groups examined participants' subjective experiences as their patient relationships evolved. Survey scores were significantly lower for participant hospice volunteers, indicating lower levels of death anxiety and communication apprehension regarding dying. An explanatory framework, using journals and focus groups, captured participants' sense of development over time into three categories: challenges, learning, and growth. This pilot project provides insight into the medical students' experiential learning as they participate in our hospice volunteer program.

Cheyne-Stokes respiration due to chronic heart failure abates with coronary artery revascularization.

A 78-year-old man presented with dyspnea and mild heart failure with Cheyne-Stokes respiration (CSR). Workup revealed inferolateral ischemia in the setting of significant triple vessel coronary disease, and nil else to adequately explain his dyspnea and eventual respiratory failure. After he underwent surgical revascularization, his ventricular function improved, leading to resolution of his respiratory failure and, of interest, his CSR. CSR is a central sleep apnea common in heart failure patients and has been associated with increased mortality. Here, we present the first English-literature report of CSR abating with surgical coronary revascularization, and briefly review the literature.

An exploration of faculty perspectives on the in-training evaluation of residents.

PURPOSE: The in-training evaluation report (ITER) is the most widely used approach to the evaluation of residents' clinical performance. Participants' attitudes toward the process may influence how they approach the task of resident evaluation. Whereas residents find ITERs most valuable when they perceive their supervisors to be engaged in the process, faculty attitudes have not yet been explored. The authors studied faculty supervisors' experiences and perceptions of the ITER process to gain insight into the factors that influence faculty engagement. METHOD: Using a grounded theory approach, semistructured interviews were completed in 2008 with a purposive sample of 17 faculty involved in resident evaluation at one Canadian medical school. Constant comparative analysis for emergent themes was conducted. RESULTS: Three major themes emerged: (1) Faculty engagement was apparent, with a widely held view that ITERs were a worthwhile endeavor. (2) Fragmentation of the evaluation system compromised evaluators' ability to produce meaningful ITERs. Fragmentation appeared to be a system problem, elements of which included time constraints, inconsistency in approach to ITE, and lack of continuity between educational assignments. (3) Faculty found the challenge of giving negative feedback daunting and struggled to avoid harming residents. CONCLUSIONS: Faculty engagement in the ITER process may be compromised by both system and interpersonal challenges. These challenges may render ITERs less meaningful than faculty intend. Training programs must complement ITE with other tools to achieve robust systems of evaluation.

NIPPV: prevalence, approach and barriers to use at Canadian ALS centres.

OBJECTIVE: The purpose of this study was to evaluate Canadian amyotrophic lateral sclerosis (ALS) centres with respect to: 1) the prevalence of Non-invasive positive pressure ventilation (NIPPV) and invasive mechanical ventilation via tracheostomy (TV) utilization, 2) the approach to NIPPV use, focusing upon the currently employed initiation criteria and 3) the barriers influencing NIPPV administration. METHODS: A descriptive survey research design aimed to obtain quantitative data and open-ended responses from an active physician at each of the 15 multidisciplinary Canadian ALS centres. RESULTS: The principal findings of this study were: 1) NIPPV and TV are used in 18.3% and 1.5% of patients at Canadian ALS centres, respectively, 2) symptoms of respiratory insufficiency, namely orthopnea (clinical significance rated at 9.00/10 +/- 1.48), dyspnea (8.27 +/- 1.95) and morning headache (7.55 +/- 1.21) are the most significant indicators for NIPPV initiation, 3) the primary barriers to NIPPV utilization are patient intolerance (70% of centres) and inaccessibility of respirologists and ventilation technologists (50% of centres). CONCLUSIONS: Variability in NIPPV use has an impact upon the management of Canadian ALS patients. The establishment of more definitive NIPPV initiation criteria, emphasizing respiratory symptoms, and the attenuation of barriers to NIPPV use should be targeted so as to ensure optimal care for all ALS patients.

The sum of the parts detracts from the intended whole: competencies and in-training assessments.

OBJECTIVES: Despite the fact that Canadian residency programmes are required to assess trainees' performance within the context of the CanMEDS Roles Framework, there has been no inquiry into the potential relationship between residents' perceptions of the framework and their in-training assessments (ITA). Using data collected during the study of ITA, we explored residents' perceptions of these competencies. METHODS: From May 2006-07, a purposive sample of 20 resident doctors from internal medicine, paediatrics, and surgery were interviewed about their ITA experiences. Data collection and analysis proceeded in an iterative fashion consistent with grounded theory. In April 2008, a summary of recurrent themes was presented during a focus group interview of another five residents to afford further elaboration and refinement of thematic findings. RESULTS: The in-training assessment report (ITAR) was perceived as a primary source of residents' information on CanMEDS. Residents' familiarity with the set of competencies appeared to be quite limited and they possessed narrow definitions of the roles. Several trainees questioned the framework's relevance and some appeared confused about the overlapping nature of the roles. Although residents viewed the central Medical Expert role as the most relevant and important competency, they incorrectly perceived it as only involving the acquisition of medical and scientific knowledge. A visual rhetorical analysis of a typical ITAR suggests that the visual features found within this assessment tool may be misrepresenting the framework and the centrality of the Medical Expert role. CONCLUSIONS: Resident doctors' knowledge of CanMEDS was found to be limited. The visual structure of the ITAR appears to be a factor in residents' apparent distortion of the CanMEDS construct from its original holistic philosophy.