Leadership's perceptions of palliative care during the COVID-19 pandemic: a qualitative study.

CONTEXT: Palliative care played a leading role in the COVID-19 pandemic. However, little is known regarding health system leadership's perceptions. BACKGROUND: This study aimed to explore the perceptions, understanding, and utilization of palliative care before compared to during the COVID-19 pandemic among health system leadership. METHODS: Semi-structured, in-depth interviews were conducted with leaders in a large healthcare system based in Massachusetts, United States. RESULTS: 22 in-depth interviews were completed at four facilities. Emerging themes included the role of palliative care before compared to during the COVID-19 pandemic, facilitators and barriers to palliative care delivery, and recommendations for future practice. Participants reported that the COVID-19 pandemic increased palliative care utilization, reinforced positive perceptions of the specialty, and emphasized its role in maximizing healthcare efficiency. Many participants found palliative care financing to be a barrier to delivery; some had an inaccurate understanding of how palliative care is reimbursed. When asked about their recommendations for improving future practice, participants noted improvements in coordination within the healthcare system and education of healthcare providers and future physicians in primary palliative care skills. CONCLUSIONS: Our findings suggest that health leadership increasingly understand the value of palliative care and its critical role within the health system and during future public health emergencies; this was further reinforced during the COVID-19 pandemic. Healthcare leadership recognize and highlight the need to increase investments in this specialty, both financially and educationally. In doing so, health care costs will be lowered, patient satisfaction will increase, and care will be better coordinated.

Community Member and Health Care Provider Perspectives on Communication With Chinese American Patients With Cancer: A Qualitative Study.

PURPOSE: Effective health care provider-patient discussions of cancer diagnoses and prognoses are essential to enhance health outcomes in oncology. Chinese Americans have been designated an underserved population in oncology by the National Institutes of Health. We explored the perspectives of Boston Chinese American community members and health care providers regarding communication preferences and decision making in oncology care. METHODS: In this inductive, qualitative study, we conducted virtual, semi-structured interviews with 21 health care providers with experience in caring for Chinese American patients with cancer and 25 older Boston Chinatown community members who self-identify as Chinese or Chinese American. Thematic analysis was performed. RESULTS: Two major themes were identified. First, provider communication should incorporate a gentle but truthful approach, careful word choice, authority-led style, and professionalism. Second, the family plays a large role in medical and nonmedical settings, and a family-centered approach to communication should be used. CONCLUSION: Our study builds on and challenges current knowledge regarding oncologic communication with Chinese American patients. A focus on the improvement of provider-patient cancer communication for Chinese Americans will improve care quality and satisfaction among patients and clinicians alike and serve to decrease disparities in care.

A Qualitative Study of the Role of Palliative Care During the COVID-19 Pandemic: Perceptions and Experiences Among Critical Care Clinicians, Hospital Leaders, and Spiritual Care Providers.

BACKGROUND: Palliative care offers a unique skill set in response to challenges posed by the COVID-19 pandemic, with expertise in advance care planning, symptom management, family communication, end-of-life care, and bereavement. However, few studies have explored palliative care's role during the pandemic and changes in perceptions and utilization of the specialty among health and spiritual care providers and hospital leaders. OBJECTIVE: To explore the utilization, perceptions, and understanding of palliative care among critical care clinicians, hospital leaders, and spiritual care providers during the pandemic. DESIGN: We conducted a qualitative study employing semi-structured, in-depth interviews. SETTING/PARTICIPANTS: We conducted the study at a tertiary academic medical center in Boston, Massachusetts, USA. Between August and October 2020, we interviewed 25 participants from 3 informant groups: (1) critical care physicians, (2) hospital leaders, and (3) spiritual care providers. RESULTS: Respondents recognized that palliative care's role increased in importance during the pandemic. Palliative care served as a bridge between providers, patients, and families; supported provider well-being; and contributed to hospital efficiency. The pandemic reinforced participants' positive perceptions of palliative care, increased their understanding of the scope of the specialty's practice, and inspired physicians to engage more with palliative care. Respondents indicated the need for more palliative care providers and advocated for their role in bereavement support and future pandemic response. CONCLUSION: Findings highlight evolving and increased utilization of palliative care during the pandemic, suggesting a need for greater investment in palliative care programs and for palliative care involvement in public health emergency preparedness and response.

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center.

PURPOSE: Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients. METHODS: We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study's exploratory nature. RESULTS: Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs. CONCLUSIONS: Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

Exploratory Study Comparing End-of-Life Care Intensity between Chinese American and White Advanced Cancer Patients at an American Tertiary Medical Center.

Background: Understanding ethnic disparities in end-of-life care (EOLC) intensity is central to improving outcomes for diverse populations. Although Chinese Americans represent one of the fastest growing ethnic groups in the United States, little is known about their EOLC intensity. Objective: To explore differences in indicators of high-intensity EOLC in the final 30 days of life, place of death, and hospice utilization between Chinese American and White advanced cancer patients. Methods: In this exploratory review, we collected data on 48 Chinese American and 48 White stage IV solid tumor patients who died during 2013-2018. Indicators of high-intensity care from the final 30 days of life included ≥2 hospital, ≥1 intensive care unit (ICU), and/or ≥2 emergency department admissions; cardiopulmonary resuscitation administration and mechanical ventilation (MV); place of death; and whether patients were on hospice at death. Results: Among Chinese American and White patients, respectively, 49% and 36% died in the hospital, 15% and 7% died in the ICU, 17% and 8% received MV, and 6% and 13% had ≥1 hospital admission lasting >14 days. Seventeen percent of Chinese American and 43% of White patients died at home. Hospice enrollment was similar between groups. Seventeen percent of Chinese American and 8% of White patients died within 30 days of diagnosis. Conclusion: Results suggest that fewer Chinese Americans died at home, whereas more died in the ICU, received MV, and died within 30 days of cancer diagnosis, indicating possible disparities in EOLC. Further studies are needed to explore findings from this exploratory investigation.

Intravenous Ketorolac Infusion for Intractable Pleuritic Pain Secondary to Metastatic Epithelioid Hemangioendothelioma.

Background: Epithelioid hemangioendothelioma (EHE) patients can experience severe pain. Nonsteroidal anti-inflammatory drugs, including ketorolac tromethamine, can effectively treat cancer-related pain, provide an opioid-sparing effect, and may be particularly effective for EHE pain. There are limited data describing prolonged (>5 days) continuous intravenous (IV) ketorolac infusion for cancer-related pain and no data on its use in EHE. Case Description: A 67-year-old woman with metastatic hepatic EHE suffered from chronic intractable pleuritic pain unresponsive to trials of nonopioid, opioid, adjuvant medications, and nonpharmacological interventions. In the hospital, continuous IV ketorolac infusion at 3.8 mg/hour (91.2 mg/day) effectively managed pain. With thorough monitoring, the patient was discharged on continuous IV ketorolac infusion at 3 mg/hour (72 mg/day). Infusion continued for 79 days without clinical or laboratory evidence of ketorolac toxicity. Conclusion: Ketorolac tromethamine as a long-term infusion is a potentially viable analgesic for patients with intractable EHE-related pain unresponsive to standard therapies.

Changes in taste and smell of food during prostate cancer treatment.

PURPOSE: The present study examined the prevalence of changes in the taste and smell of food among men with advanced prostate cancer who were receiving hormone therapy and/or chemotherapy. METHOD: Participants were 75 men with advanced prostate cancer treated at an academic medical center. They completed a prospective survey about nausea while eating, taste and smell of food, and appetite periodically during a mean of 1.3 years of follow-up. Demographics, treatments, and weight data were extracted from electronic health records. Logistic regression analyses were used to examine the associations between the presence of the symptoms surveyed, treatments, and weight loss of ≥10%. RESULTS: Participants experienced poor taste of food (17%) and poor smell of food (8%) during the study. Nausea was associated with an increased likelihood of experiencing poor taste (50.0% v 12.3%, OR=7.13, P=.008) and smell (30.0% v 4.6%, OR=8.86, P=.016) of food. Poor taste of food was associated with an increased likelihood of experiencing poor appetite (35.0% v 10.9%, OR=12.43, P<.001). Participants were more likely to experience poor taste of food at any point in the study if they were being treated with denosumab (35.0% v 10.9%, OR=4.40, P=.020) or docetaxel (41.7% v 12.7%, OR=4.91, P=.022). Participants were more likely to experience ≥10% weight loss if experiencing poor taste of food (38.4% v 8.6%, OR=6.63, P=.010) or poor appetite (60.0% v 6.6%, OR=21.38, P<.001). CONCLUSION: Clinicians should query patients for changes in taste and smell of food, especially if they are experiencing weight loss.