Mortality After Elective Surgery: The Potential Role for Preoperative Palliative Care.

BACKGROUND: Preoperative optimization is increasingly emphasized for high-risk surgical patients. One critical component of this includes preoperative advanced care planning to promote goal-concordant care. We aimed to define a subset of patients that might benefit from preoperative palliative care consult for advanced care planning. MATERIALS AND METHODS: We examined adult patients admitted from January 2016 to December 2018 to a university health system for elective surgery. Multivariate logistic regression was used to identify variables associated with death within 1 y, and presence of palliative care consults preoperatively. Chi-square analysis evaluated the impact of a palliative care consult on advanced care planning variables. RESULTS: Of the 29,132 inpatient elective procedures performed, there was a 2.0% mortality rate at 6 mo and 3.5% at 1 y. Those who died were more likely to be older, male, underweight (BMI <18), or have undergone an otolaryngology, neurosurgery or thoracic procedure type (all P-values < 0.05). At the time of admission, 29% had an advance directive, 90% had a documented code status, and 0.3% had a preoperative palliative care consult. Patients were more likely to have an advanced directive, a power of attorney, a documented code status, and have a do not resuscitate order if they had a palliative care consult (all P-values <0.05). The mortality rates and preoperative palliative care rates per procedure type did not follow similar trends. CONCLUSIONS: Preoperative palliative care consultation before elective admissions for surgery had a significant impact on advanced care planning.

The impact of palliative care on quality of life, anxiety, and depression in idiopathic pulmonary fibrosis: a randomized controlled pilot study.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a fatal disease that results in poor quality of life due to progressive respiratory symptoms, anxiety, and depression. Palliative care improves quality of life and survival in other progressive diseases. No randomized controlled trials have investigated the impact of palliative care on quality of life, anxiety, or depression in IPF. METHODS: We conducted a randomized, controlled, pilot study to assess the feasibility of measuring the effect of a palliative care clinic referral on quality of life, anxiety, and depression in IPF. Patients were randomized to usual care (UC) or usual care + palliative care (UC + PC) with routine pulmonary follow up at 3 and 6 months. The UC + PC group received a minimum of one PC clinic visit. Primary outcome was change from baseline in quality of life, anxiety, and depression as measured by the St. George's Respiratory Questionnaire (SGRQ), the Hospital Anxiety and Depression Index (HADS), and the Patient Health Questionnaire (PHQ-9) at 6 months. RESULTS: Twenty-two patients were randomized between September 2017 through July 2018; 11 to UC and 11 to UC + PC. There was no difference in the change in SGRQ score at 3 months or 6 months, however, the symptom score trended towards a significant worsening for UC + PC at both 3 and 6 months (mean change at 3 months for UC and UC + PC was - 7.8 and + 10.7, respectively, p = 0.066; mean change at 6 months for UC and UC + PC was - 6.0 and + 4.6, respectively, p = 0.055). There was no difference in the change in HADS anxiety or depression scores. There was a significant transient worsening in PHQ-9 scores for UC + PC at 3 months (UC: -1.6, UC + PC: + 0.9, p = 0.008); this effect did not persist at 6 months. CONCLUSION: This pilot study demonstrated that a randomized controlled trial of palliative care in idiopathic pulmonary fibrosis patients is feasible. Receiving palliative care did not lead to improved quality of life, anxiety, or depression compared to usual care after 6 months. Patients in the UC + PC group trended towards worsening symptoms and a small but statistically significant transient worsening in depression. These findings should be interpreted with caution, and need to be evaluated in adequately powered clinical trials. NCT03981406, June 10, 2019, retrospectively registered.

A Regional Survey of Attitudes and Experiences in Determining When to Prescribe Intranasal Naloxone for Patients Seen in Palliative Care Clinics in the United States of America.

Background: Published guidelines that help clinicians identify patients who would benefit from the co-prescription of intranasal naloxone (IN) exclude "palliative care patients." In the absence of clear care standards, palliative care (PC) clinicians may experience uncertainty in how to approach IN co-prescriptions. Objective: Explore the attitudes of PC clinicians in the United States of America who work at regional health care institutions regarding IN prescriptions for patients they prescribe opioids for. Methods: An 18-question electronic survey was distributed to PC clinicians that practice at institutions in Wisconsin or Minnesota with at least 10 other PC clinicians between February and May 2023. The survey explored clinical scenarios in which respondents would and would not prescribe IN. Results: Fifty-six PC clinicians responded to the survey-response rate 41%. Most respondents (90.9%) did not feel IN prescriptions should be reserved for patients with a full code status; 67.9% of respondents felt that IN prescriptions are reasonable for certain patients with a terminal illness and comfort goals of care. Neither prognosis, duration of opioid therapy, nor dose of opioid therapy were significant factors in determining whether most respondents prescribed IN for their patients. Most respondents (81.8%) felt clinician counseling and patient consent were essential before prescribing IN. Conclusion: Most PC clinicians in our survey felt that IN prescriptions can be appropriate for patients they prescribe opioids for. Bystander safety was an emerging rationale for why respondents chose to prescribe IN for their patients. Despite public health efforts to make IN more freely available, most respondents felt clinician counseling was essential before prescribing IN for their patients.

Methadone-Induced Neurotoxicity in Advanced Cancer: A Case Report.

Methadone use as a second-line agent for severe cancer-related pain is increasing in the field of hospice and palliative care. It has a number of qualities that make its use favorable, including lack of known active metabolites and presumed relative safety from adverse effects such as opioid-induced neurotoxicity (OIN). This article describes a case of a patient undergoing treatment of severe cancer-related pain who developed OIN in the setting of oral methadone use. As the use of methadone increases, more research into its pharmacologic and pharmacokinetic properties will be necessary.

Case report: are clinicians obligated to medically treat a suicide attempt in a patient with a prognosis of weeks?

BACKGROUND: There is broad ethical and professional consensus that preventing a patient from initiating or successfully completing a suicide attempt is a core physician obligation and justifies the use of aggressive interventions such as emergency detention and mechanical ventilation. This case examines the acute medical care of an individual with a progressive brain tumor after an apparent suicide attempt. RESULTS: In guiding the care of this patient, we found that the patient's prognosis of days to weeks made the ethical rationale of implementing aggressive medical interventions to treat the sequelae of his suicide attempt less compelling.

The educational impact of weekly e-mailed fast facts and concepts.

PURPOSE: Educational interventions such as electives, didactics, and Web-based teaching have been shown to improve residents' knowledge, attitudes, and skills. However, integrating curricular innovations into residency training is difficult due to limited time, faculty, and cost. In this study, the authors assessed the educational impact of weekly Fast Facts and Concept (FFAC) e-mails on residents' knowledge of palliative care topics, self-reported preparedness in palliative care skills, and satisfaction with palliative care education. METHOD: Internal medicine interns at the University of Pittsburgh and Medical College of Wisconsin were randomized to control and intervention groups in July 2009. Pretests and posttests assessed medical knowledge through 24 multiple choice questions, preparedness on 14 skills via a 4-point Likert scale and satisfaction based on ranking of education quality. The intervention group received 32 weekly e-mails. RESULTS: The study group included 82 interns with a pretest response rate of 100% and posttest response rate of 70%. The intervention group showed greater improvement in knowledge than the control (18% increase compared to 8% in the control group, p = 0.005). Preparedness in symptom management skills (converting between opioids, differentiating types of pain, treating nausea) improved in the intervention group more than the control group (p = 0.04, 0.01, and 0.02, respectively). There were no differences in preparedness in communication skills or satisfaction between the control and intervention groups. CONCLUSIONS: E-mailed FFAC are an educational intervention that increases intern medical knowledge and self-reported preparedness in symptom management skills but not preparedness in communication skills or satisfaction with palliative care education.