Managing pain with algorithms: an opportunity for improvement? Or: the development and utilization of algorithms to manage acute pain.

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

The value of an educational video before consultation with a radiation oncologist.

This study aims to assess the efficacy of a radiation therapy (RT) education video for patients referred for treatment. The investigators produced a 23-min guide to radiation therapy DVD, combining didactic material and patient narratives. Patients (n=32) had not yet received their initial consultation. Baseline awareness about cancer and treatment was assessed by surveys including the rapid estimate of adult literacy in medicine. Knowledge about RT was assessed before and after viewing the video with a separate 21 question survey. Differences in benefit for sociodemographic subgroups including age, gender, ethnicity, income, education, and health literacy level were explored. Baseline assessments identified 78 % of patients regardless of sociodemographic status had "little" to "no" basic knowledge of RT. The mean number of correct responses in the 21 question survey assessing how RT works improved from 9.8 to 11.1 after watching the video (p<0.0001; 95 % CI: 1.3-3.0), a statistically significant benefit that was present among all sociodemographic subgroups, but more prominent among those with a greater than high school education (p=0.002). Patient satisfaction with the video was high. Knowledge among cancer patients regarding RT is poor, regardless of sociodemographic factors. This pilot study demonstrates the utility of a brief video to universally improve patient awareness about RT. While patients may ultimately learn about RT during their course of treatment, we advocate for any tools that can improve patient knowledge at the time of initial consultation as this is typically the time they are asked to acknowledge informed consent for treatment.

Creating a Blueprint of Well-Being in Oncology: An Approach for Addressing Burnout From ASCO's Clinician Well-Being Taskforce.

Optimizing the well-being of the oncology clinician has never been more important. Well-being is a critical priority for the cancer organization because burnout adversely impacts the quality of care, patient satisfaction, the workforce, and overall practice success. To date, 45% of U.S. ASCO member medical oncologists report experiencing burnout symptoms of emotional exhaustion and depersonalization. As the COVID-19 pandemic remains widespread with periods of outbreaks, recovery, and response with substantial personal and professional consequences for the clinician, it is imperative that the oncologist, team, and organization gain direct access to resources addressing burnout. In response, the Clinician Well-Being Task Force was created to improve the quality, safety, and value of cancer care by enhancing oncology clinician well-being and practice sustainability. Well-being is an integrative concept that characterizes quality of life and encompasses an individual's work- and personal health-related environmental, organizational, and psychosocial factors. These resources can be useful for the cancer organization to develop a well-being blueprint: a detailed start plan with recognized strategies and interventions targeting all oncology stakeholders to support a culture of community in oncology.

Ovarian suppression in the management of premenopausal breast cancer: methods and efficacy in adjuvant and metastatic settings.

Ovarian suppression has been used to treat hormone-responsive metastatic breast cancer in premenopausal women for over 100 years and is currently under continued evaluation for treatment in the adjuvant setting. In this article, ovarian suppression by surgery, radiation, and pharmacological therapy is discussed, including the risks, benefits, and efficacy of each strategy. The role of ovarian suppression in premenopausal women with early and advanced stages of breast cancer will be reviewed. It is hoped that this review will assist clinicians and their patients in selecting the appropriate therapy if ovarian suppression is indicated.

Palliative care consultation in the process of organ donation after cardiac death.

Palliative care consultation has been demonstrated to be useful in many situations in which expert symptom management, communication around sensitive issues, and family support may serve to enhance or improve care. The process of organ donation is an example of this concept, specifically the process of donation after cardiac death (DCD). DCD allows patients with severe, irreversible brain injuries that do not meet standard criteria for brain death to donate organs when death is declared by cardiopulmonary criteria. The DCD method of donation has been deemed an ethically appropriate means of organ donation and is supported by the organ procurement and medical communities, as well as the public. The palliative care (PC) team can make a significant contribution to the care of the patient and family in the organ donation process. In this paper we describe the controlled DCD process at one institution that utilizes the PC team to provide expert end-of-life care, including comprehensive medical management and family support. PC skills and principles applicable to the DCD process include communication, coordination of care, and skillful ventilator withdrawal. If death occurs within 90 minutes of withdrawal of life support, organs may be successfully recovered for transplantation. If the patient survives longer than 90 minutes, his or her care continues to be provided by the PC team. Palliative care can contribute to standardizing quality end-of-life care practices in the DCD process and provide education for involved personnel. Further experience, research and national discussions will be helpful in refining these practices, to make this difficult and challenging experience as gentle and supportive as possible for the courageous families who participate in this process.

Cultural perceptions in cancer care among African-American and Caucasian patients.

PURPOSE: This exploratory study examined perceptions and beliefs of African Americans and Caucasians related to cancer care. Understanding belief systems and cultures optimizes cancer treatment and care delivery to ethnic minority individuals. PATIENTS AND METHODS: Focus groups were conducted with 39 African-American and Caucasian cancer patients. Data analysis included whole group analysis with a team of five researchers. RESULTS: Regardless of ethnicity, cancer patients share many of the same emotions and experiences, and want complete information and quality care. Differences were also apparent. African-American participants were more likely to report increased religious behaviors, believe that healthcare providers demonstrate care with simple actions and provision of practical assistance, and use church and community information sources. Caucasian participants were more likely to report spiritual but not overtly religious changes, and depend on healthcare providers for information. CONCLUSION: Understanding how culture colors perceptions, communication and information requirements is critical to providing effective care to ethnically diverse cancer patients. Findings have implications for professionals understanding ways patients seek information, the role of spirituality and religion in care, and ways healthcare providers demonstrate care.

Beyond the IRB: examining common but rarely explored ethical issues in psychosocial research.

This article discusses common ethical and practical considerations in psychosocial and behavioral research in healthcare. Issues such as appropriate objectives and intent, risk-benefit ratios, research design, and human subject protection are explored. The burden of ethical research design and implementation is placed on the investigator, rather than relying solely on institutional review boards to judge individual projects. The benefit of acquisition of knowledge must be balanced against the burdens of the research on society in general and human subjects specifically. Scientific replication of research is encouraged, unnecessary duplication defined and discouraged, and benefits of true collaboration outlined. Investigators are advised to consider the context, intent, purpose, implementation, and use of information when developing research. The concept of "researcher myopia" is defined as a common stumbling block. It is suggested that academic researchers also look to other disciplines, such as industry, for examples of research that is concise, cost-effective, and reliable.

A principle-based approach to ethical issues in predictive genetic testing for breast cancer.

Genetic breast cancer susceptibility testing presents ethical challenges for healthcare providers and their patients. The familial aspects of genetic information, recognition of DNA as a shared history and present common thread for all people and widespread misunderstandings of genetic tests all contribute to these challenges. In this article an ethical framework internationally developed as a charter for medical professionalism is used to guide approaches to ethical dilemmas of breast cancer genetic testing. Specifically, three ethical principles are explored as they relate to testing: primacy of patient, patient autonomy, and social justice. Approaching breast cancer genetic testing from this framework could help to ensure thoughtful and ethical practices in this rapidly evolving field.

Improving palliative and supportive care in cancer patients.

Twenty years of research in controlling symptoms such as pain and nausea have shown persistent suboptimal performance by the US oncology system. The data suggest that some of the tools of palliative care programs can improve physical symptoms of seriously ill patients at a cost society can afford. To fix these problems will require recognition of the symptoms or concerns, a system such as an algorithm or care plan for addressing each, measurement of the change, and accountability for the change. Symptom assessment scales such as the Edmonton Symptom Assessment Scale or Rotterdam Symptom Check List work to make symptoms manifest. Listing symptoms on a problem list is a necessary step in addressing them. Physical symptoms such as pain can be improved by use of computer prompts, algorithms, dedicated staff time, team management, or combinations of these strategies. Less concrete problems such as medically appropriate goal-setting, integrating palliative care into anticancer care sooner, and informing patients about the benefits and risks of chemotherapy near the end of life require more complex solutions. We review what is known about symptom control in oncology, how and why some programs do better, and make suggestions for practice. Finally, we suggest a practical plan for using symptom assessment scales, listing the problems, and managing them according to algorithms or other predetermined plans.

The "PSOST": Providers' Signout for Scope of Treatment.

Palliative care provides open and honest communication, medically appropriate goal setting, and meticulous attention to symptom assessment and control. The Physicians Orders for Life Sustaining Treatment (POLST) is a growing movement to allow health care providers to indicate, with their patients, what they want done in specific situations, such as feeding tubes, mechanical ventilation, or transfer to an intensive care unit. We have developed an internal signout tool used by palliative medicine fellows in our institution to specify similar interventions-or not-with seriously ill palliative care patients, the Providers Signout for Scope of Treatment (PSOST). We have found that this situation-specific tool enables smooth transitions of care on nights and weekends, especially when the patient is near death, and may help prevent both overescalation of care and underuse of life saving treatments such as resuscitation. The PSOST differs from other signout tools in that it gives clear direction regarding the patient's medical goals and desire for escalation of care, or not. We present it here for open access and use anywhere. This tool has also assisted in building team communication with the nursing shifts, especially nights and weekends, as all team members are able to deliver a consistent message, while meeting the goals of care for patients and families. We believe this tool could be useful with a broader patient population, outside of Palliative Medicine, to provide clearer direction for hospitalized or nursing home patients whose care is often directed by multiple providers. It could also be used as a template for signouts on other inpatient services, as care goals are important for all patients.

Barriers to effective palliative care for low-income patients in late stages of cancer: report of a study and strategies for defining and conquering the barriers.

The discipline of palliative care is growing rapidly in the United States but, as in many other areas of medical care, multiple barriers exist to providing such care to low-income patients with end-stage cancer and other diseases. Reports vary with regard to definition and scope of these and other barriers. This article briefly reports a pilot study of perceived barriers to palliative care and related issues in an urban cancer clinic, reviews the current literature, and suggest ways to identify and overcome such barriers in low-income patients with cancer.

Clinical and financial impact of a palliative care program at a small rural hospital.

BACKGROUND: Palliative care (PC) programs attempt to improve communication and symptom management, and a consequence has been lower cost of in-hospital death. To date, most research has focused on urban large hospitals. This study reports the clinical and financial impact of a new palliative care service at a 76-bed nonprofit hospital located in rural Virginia, Rappahannock General Hospital (RGH). METHODS: The RGH PC program started in 2006 with a part-time physician on grant support. We collected the number of consults, physician billing and receipts, and calculated the impact on the hospital's charges for patients treated with concurrent palliative care. RESULTS: The program was well accepted clinically with referrals from most of the palliative care physician's colleagues. After the first year of operation, she has about 10 new consults and a total of 45 visits per month. Billings for this year are projected to be $59,070 and her collections are projected to be $29,604 (50%). Hospital charges per patient are reduced about $400 per day, or 25%, after a palliative care consultation, which sums to $80,000 to $130,000 yearly. Referrals to home hospice increased. CONCLUSIONS: Palliative care by a dedicated practitioner can work in rural areas. The income will be small, but the operational and financial benefits to the hospital can be significant. This is better care at a cost that rural hospitals and practitioners can afford.

Strategies for avoiding burnout in hospice and palliative medicine: peer advice for physicians on achieving longevity and fulfillment.

BACKGROUND: Hospice and palliative medicine (HPM) is now an American Board of Medical Specialties-recognized subspecialty, and many physicians are choosing it as a career. There is little written about recognition and prevention of burnout or physician self-care in this challenging and ever-evolving field. METHODS: We conducted a qualitative online survey of 40 HPM physicians practicing in the United States and asked them to comment on their strategies for avoiding burnout and finding fulfillment in palliative medicine. Responses were coded into thematic classes by commonalities. RESULTS: Thirty of 40 HPM physicians (19 males, 11 females) surveyed responded in full. Each listed between 1 to 7 strategies (median 4 per respondent) they felt to be important in preventing burnout that were placed in 1 of 13 thematic classes. Physical well-being was the most common strategy reported (60%), followed by professional relationships (57%), taking a transcendental perspective (43%), talking with others (43%), hobbies (40%), clinical variety (37%), personal relationships (37%), and personal boundaries (37%). "Time away" from work (27%), passion for one's work (20%), realistic expectations and use of humor and laughter (13% each), and remembering patients (10%) were cited less frequently. CONCLUSIONS: HPM physicians report using a variety of strategies to promote their personal well-being suggesting a diversified portfolio of wellness strategies is needed to deal with the challenges of palliative care medicine. Additional studies are needed to help HPM recognize burnout in their practices and among their colleagues, and to determine how to help future HPM physicians develop individualized strategies to promote personal wellness and resilience.