Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial.

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

Patient Experiences of Specialty Palliative Care in the Perioperative Period for Cancer Surgery.

CONTEXT: Though patients undergoing treatment for upper gastrointestinal (GI) cancers frequently experience a range of sequelae and disease recurrence, patients often do not receive specialty palliative care soon after diagnosis and it is unknown in what ways they may benefit. OBJECTIVES: To understand patient experiences of specialty palliative care in the perioperative period for patients seeking curative intent upper GI oncologic surgery. METHODS: As part of a randomized controlled trial, we conducted in-depth interviews between November 2019 and July 2021 with 23 patients in the intervention arm who were undergoing curative intent treatment for upper GI cancers and who were also followed by the specialty palliative care team. RESULTS: We found five themes that characterized patient experiences and perceptions of specialty palliative care. Patients typically had limited prior awareness of palliative care (theme 1), but during the study, came to understand it as a "talking" intervention (theme 2). Patients whose concerns aligned with palliative care described it as being impactful on their care (theme 3). However, most patients expressed a focus on cure from their cancer and less perceived relevance for integration of palliative care (theme 4). Integrating specialist palliative care practitioners with surgical teams made it difficult for some patients to identify how palliative care practitioners differed from other members of their care team (theme 5). CONCLUSION: While receipt of specialty palliative care in the perioperative period was generally perceived positively and patients appreciated palliative care visits, they did not describe many needs typically met by palliative care practitioners. TRIAL REGISTRATION: clinicaltrials.gov registration: NCT03611309.

A Hospice Transitions Program for Patients in the Emergency Department.

Importance: Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective: To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants: This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures: The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results: This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). Conclusions and Relevance: In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial.

Importance: Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. Objective: To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. Design, Setting, and Participants: From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Intervention: Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. Main Outcomes and Measures: The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. Results: In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). Conclusions and Relevance: To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. Trial Registration: ClinicalTrials.gov Identifier: NCT03611309.

Dexmedetomidine: A Novel Strategy for Patients with Intractable Pain, Opioid-Induced Hyperalgesia, or Delirium at the End of Life.

Dexmedetomidine, a selective alpha2 agonist, is traditionally used briefly for perioperative anesthesia and sedation of mechanically ventilated patients. Reports of its use in patients with opioid-induced hyperalgesia1 and intractable pain and delirium2 suggested it for patients who otherwise may have required palliative sedation to relieve suffering. We present the protocol developed by the interdisciplinary team in our intensive palliative care unit that allows for safe titrated administration without required vital sign monitoring outside the intensive care unit (ICU) (Supplementary Appendix SA1). We describe its efficacy in eight patients who were receiving comfort-focused care.

Application of Kern's 6-Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions.

BACKGROUND: Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking. METHODS: Using Kern's 6-step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy. RESULTS: Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective-structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence-based best practices content covering professional guidelines, current literature, shared decision-making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions. CONCLUSION: Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision-making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.

A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC).

Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).

Usage Patterns of a Mobile Palliative Care Application.

BACKGROUND: Fast Facts Mobile (FFM) was created to be a convenient way for clinicians to access the Fast Facts and Concepts database of palliative care articles on a smartphone or tablet device. We analyzed usage patterns of FFM through an integrated analytics platform on the mobile versions of the FFM application. OBJECTIVE: The primary objective of this study was to evaluate the usage data from FFM as a way to better understand user behavior for FFM as a palliative care educational tool. DESIGN: This is an exploratory, retrospective analysis of de-identified analytics data collected through the iOS and Android versions of FFM captured from November 2015 to November 2016. MEASUREMENTS: FFM App download statistics from November 1, 2015, to November 1, 2016, were accessed from the Apple and Google development websites. Further FFM session data were obtained from the analytics platform built into FFM. RESULTS: FFM was downloaded 9409 times over the year with 201,383 articles accessed. The most searched-for terms in FFM include the following: nausea, methadone, and delirium. We compared frequent users of FFM to infrequent users of FFM and found that 13% of all users comprise 66% of all activity in the application. CONCLUSIONS: Demand for useful and scalable tools for both primary palliative care and specialty palliative care will likely continue to grow. Understanding the usage patterns for FFM has the potential to inform the development of future versions of Fast Facts. Further studies of mobile palliative care educational tools will be needed to further define the impact of these educational tools.

The Intensive Palliative Care Unit: Changing Outcomes for Hospitalized Cancer Patients in an Academic Medical Center.

BACKGROUND: Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Women's Cancer Center, the intensive palliative care unit (IPCU) admits symptomatic oncology patients with uncontrolled symptoms throughout the trajectory of illness. Patients are uniquely managed by an interdisciplinary team of clinicians who focus on symptom management and advance care planning. OBJECTIVE: The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU. DESIGN: We retrospectively reviewed 74 oncology patients admitted to the IPCU in August and September, 2013. RESULTS: A total of 67 IPCU patients who were admitted received palliative intent treatment, whereas 7 patients received curative intent care. All patients were engaged in a goals-of-care discussion during admission. Of the palliative intent patients, 58% were transferred to the IPCU from medical oncology and 42% were directly admitted. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint at admission. Twenty-five patients experienced a change in code status from Full Code to do-not-resuscitate/do-not-incubate. A total of eight patients died in the IPCU, and 50% experienced a code status change. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30-day readmission was 4%. CONCLUSIONS: Among advanced cancer patients, our findings suggest that an inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases hospital readmissions.

Utility of the "Surprise" Question in Predicting Survival among Older Patients with Acute Surgical Conditions.

BACKGROUND: The surprise question is a validated tool for identifying patients with increased risk of death within one year who could, therefore, benefit from palliative care. However, its utility in surgery is unknown. OBJECTIVE: We sought to determine whether the surprise question predicted 12-month mortality in older emergency general surgery patients. DESIGN: This was a prospective cohort study. SETTING/SUBJECTS: Emergency general surgery attendings and surgical residents in or beyond their third year of training at a single tertiary care academic hospital from January to July 2014. MEASUREMENTS: Surgeons responded to the surprise question within 72 hours of evaluating patients, ≥65 years, hospitalized with an acute surgical condition. Patient data, including demographic and clinical characteristics, were extracted from the medical record. Mortality within 12 months of initial evaluation was determined by using Social Security death data. RESULTS: Ten attending surgeons and 18 surgical residents provided 163 responses to the surprise question for 119 patients: 60% of responses were "No, I would not be surprised" and 40% were "Yes, I would be surprised." A "No" response was associated with increased odds of death within 12 months in binary logistic regression (OR 4.8 [95% CI 2.1-11.1]). CONCLUSIONS: The surprise question is a valuable tool for identifying older patients with higher risk of death, and it may be a useful screening criterion for older emergency general surgery patients who would benefit from palliative care evaluation.

Timing of hospice referral and families' perceptions of services: are earlier hospice referrals better?

OBJECTIVES: To determine whether families of patients who enroll in hospice near the end of life believe that they receive less benefit from hospice services than families of patients who enroll earlier. DESIGN: Semistructured interviews at the time of hospice enrollment and 1 month after the patient's death. SETTING: This study was conducted at the Hospice of Lancaster County, Lancaster, PA, over a 12-month period spanning 2003-2004. PARTICIPANTS: First-time hospice admissions. MEASUREMENTS: Interviews assessed the anticipated helpfulness of six hospice services (enrollment interviews) and the actual helpfulness of the same services (follow-up interviews). RESULTS: Length of stay in hospice was associated with families' reports of the number of services provided (Spearman rho=0.34, P<.001), and with the mean helpfulness ratings for the services that were provided (Spearman rho=0.34, P<.001), although even with short lengths of stay, most families reported that they received the services that they anticipated and that those services were helpful. CONCLUSION: These results indicate that families feel they receive greater benefits from longer lengths of stay in hospice. Future efforts to define an "optimal" length of stay in hospice should consider patients' and families' perceptions of the benefits that hospice offers.

How well are we caring for caregivers? Prevalence of grief-related symptoms and need for bereavement support among long-term care staff.

To define the prevalence and correlates of grief-related symptoms among long-term care staff who care for patients near the end of life, a cross-sectional survey was conducted at six Program of All-inclusive Care for the Elderly (PACE) organizations that provide long-term care in the home and in institutions. All clinical and non-clinical program staff were surveyed to examine the prevalence of 20 grief-related symptoms and assess current sources of bereavement support, as well as willingness to use additional sources of support. Surveys were completed by 203/236 staff (86%), who described a wide variety of symptoms they attributed to the death of one of their patients in the past month. Most staff (147/203; 72%) reported at least one symptom. Staff with more symptoms had experienced more patient deaths in the past month (Spearman rho = 0.20, P = 0.007), had worked for a longer time at a PACE organization (Spearman rho = 0.16, P = 0.031), and reported a closer and longer relationship with the last patient who died (Spearman rho = 0.32, P < 0.001; rho = 0.24, P = 0.001). Although staff identified several informal sources of bereavement support (mean 2.3 sources, range 0-6), almost all (n = 194; 96%) said they would use additional support services if they were offered. These community-based long-term care staff experience a variety of symptoms attributable to the deaths of their patients, and would welcome additional sources of bereavement support.

Are we referring patients to hospice too late? Patients' and families' opinions.

BACKGROUND: Patients typically receive hospice care only in the last days or weeks of life, and there is widespread agreement among experts that patients enroll in hospice too late. However, it is not known whether patients and their families believe that they are enrolling in hospice too late. DESIGN: Prospective interview study. SETTING: Not-for-profit, Medicare-certified hospice. PATIENTS: Patients and families recruited at consecutive hospice enrollment visits. MEASUREMENTS: Interviews at the time of hospice enrollment and 1 month after death or discharge from hospice assessed patients' and families' perceptions of the timing of hospice enrollment ("too soon," "too late," "at about the right time"). RESULTS: Interviews were conducted at 274 enrollment visits. Very few patients (1/85; 1%) and family members (12/261; 5%) said that they believed they were enrolling in hospice too late. In follow-up interviews with families after the patient's death or discharge, families were more likely to believe that enrollment was too late (n = 38/218; 17%; sign test p < .001). Families who believed they had enrolled too late had shorter lengths of stay in hospice compared to those who said that enrollment was too soon or at the right time (median 10 vs. 24 days; rank-sum test p < 0.001). CONCLUSION: Despite late enrollment in hospice and very short lengths of stay, most patients and families believe that they are enrolling in hospice at the right time.

Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population?

BACKGROUND: Hospices provide care to patients with a wide range of prognoses, and must develop care plans that anticipate each patient's likely illness trajectory. However, the tools available to guide prognostication and care planning in this population have limited data to support their use. For instance, one of the most widely-used prognostic tools, the Palliative Performance Scale (PPS), has been studied primarily in inpatient settings and in patients with cancer. Its prognostic value in a heterogeneous US hospice population is unknown. OBJECTIVE: The goal of this study was to evaluate the prognostic value of the PPS as a predictor of mortality in a heterogeneous hospice population, and to determine whether it performs equally well across diagnoses and sites of care. DESIGN: Prospective cohort study using existing medical records. SETTING/SUBJECTS: This study was conducted at a large community hospice program, and included all patients enrolled in hospice during the study period. MEASUREMENTS: Each patient's PPS score was recorded at the time of enrollment and patients were followed until death or discharge from hospice. RESULTS: A total of 466 patients enrolled in hospice during the study period. The PPS score was a strong independent predictor of mortality (log rank test of Kaplan Meier survival curves p < 0.001). Six-month mortality rates for 3 PPS categories were 96% (for PPS scores 10-20), 89% (for PPS scores 30-40), and 81% (for PPS scores > or =50). Evaluation of interaction terms in Cox proportional hazards models demonstrated a stronger association between PPS score and mortality among nursing home residents and patients with non-cancer diagnoses. Analysis of the area under receiver operating characteristic curves demonstrated strong predictive value overall, with somewhat greater accuracy for nursing home residents and patients with noncancer diagnoses. CONCLUSION: The PPS performs well as a predictor of prognosis in a heterogeneous hospice population, and performs particularly well for nursing home residents and for patients with non-cancer diagnoses. The PPS should be useful in confirming hospice eligibility for reimbursement purposes and in guiding plans for hospice care.