Journal of pain and symptom management最新文献

Context: Needs assessment in palliative care is essential for drawing up personalized care plans that improves the quality of life of the patient and their family by preventing and alleviating suffering and addressing unmet needs. Our group recently developed a guide to Multidimensional needs Assessment in the Palliative care initial encounter (MAP), and its applicability in different care settings has been confirmed. However, the professionals consulted also suggested a number of possible improvements for its implementation in clinical practice.

Objectives: To refine the MAP clinical interview guide through expert consensus.

Methods: Twenty-two palliative care physicians who had previously implemented MAP participated in a two-round Delphi study conducted in accordance with the CREDES guidelines. The threshold for consensus was set at 80% agreement among panellists. The Delphi findings were subsequently discussed by a nominal group of 10 (different) palliative care experts to achieve a final consensus, following the four-step meeting process described by Van de Ven and Delbecq. Consensus was sought on the removal of less frequent needs and including the assessment of advance directives and wish to hasten death.

Results: The revised version of the MAP guide comprises 48 needs. It was agreed that advance directives and a possible wish to hasten death should be added to the domain relating to spiritual/existential concerns, and also that less frequent physical symptoms (e.g., pruritus, myoclonus) and the use of complementary therapies should be retained in the guide. Experts also stressed the importance of concluding the initial assessment by returning to the patient's main concerns and prioritizing their most urgent needs.

Conclusion: The revised MAP guide incorporates advance directives and a possible wish to hasten death as key issues to explore, reinforcing its utility as a tool for the comprehensive assessment of patients' needs in the palliative care initial encounter. Its use may support the development of individualized care plans and future research should explore its applicability and benefits in clinical practice.

Background: Specialty palliative care improves quality of life, symptoms, and goal-concordant care, with greatest benefits when delivered at "full dose" (appropriate timing, intensity, and clinician expertise). Yet access is inequitable, particularly for racial and ethnic minority patients treated at minority-serving institutions (MSIs). Limited methods for identifying palliative care consultations in national datasets hinder progress in studying disparities.

Methods: We developed a novel billing-based approach to identify specialty palliative care consultations by linking three data sources from the Mount Sinai Health System (2021-2022): 1) administrative billing data with clinician identifiers, 2) a palliative care consultation registry, and 3) board certification datasets for physicians and nurse practitioners. Consultations were identified using two approaches: clinician National Provider Identifiers (NPIs) flagged for board certification and the ICD-10 Z51.5 code ("Encounter for Palliative Care"). Both were compared against the registry "gold standard."

Results: Board-certified NPIs identified consultations with sensitivity of 64% and specificity of 96%. The Z51.5 code demonstrated high specificity overall (99%) but reduced specificity among patients who died in-hospital (75%) and low sensitivity (∼50%). Many consultations were delivered by non-board-certified clinicians, underscoring limitations of certification-based definitions.

Conclusions: Linking billing, registry, and certification data provides a feasible method for measuring specialty palliative care consultations. However, strict reliance on board certification underestimates care delivered by the workforce, particularly at MSIs. Improved measurement approaches are essential for accurately assessing structural racism in access to palliative care and for guiding equitable workforce and policy interventions.

Background & objective: Parent caregivers of children with medical complexity (CMC) provide continuous, multidimensional care over decades. Given that the growing CMC population now comprises most of pediatric palliative care (PPC) patients, palliative care clinicians are positioned to support parents in discipline- and expertise-specific ways distinct from pediatric complex care and other subspecialties. This study aimed to identify CMC parent caregiver challenges that can be optimally addressed using PPC expertise.

Methods: This secondary qualitative analysis of semi-structured interviews with CMC parents explored caregiving challenges, using thematic analysis to identify themes. Themes were synthesized to identify potential levers for subspecialty palliative care-specific interventions and drive design of a conceptual framework to inform the ongoing development and implementation of PPC services for CMC parent caregivers.

Results: Nineteen CMC parent caregivers participated in interviews, most of whose children had chronic health conditions affecting primarily the neurologic/neuromuscular, gastrointestinal, and respiratory systems. Almost all represented children were supported by medical technology and relied on Medicaid for primary insurance coverage. Parent report of challenges that may be addressed by PPC highlighted three themes: being unseen in their care work, tackling unrelenting caregiving responsibilities, and facing uncertainty-henceforth referred to as "the 3U's." Each of these themes presented at three levels-the personal, the healthcare system, and the community.

Conclusion: CMC parents' distressing caregiving challenges fall into three themes, which suggest key levers for clinicians aiming to support parent caregivers. This qualitative analysis offers guidance on how to optimally use a PPC-specific skillset for parent caregiver support.

Background: Cancer-related hip pain due to tumor infiltration is challenging, especially in patients with limited life expectancy. While ultrasound-guided pericapsular nerve group (PENG) phenol neurolysis has been reported in isolated cases, systematic evidence on effectiveness and safety remains limited.

Methods: We conducted a prospective case series of three patients with refractory metastatic hip pain who underwent ultrasound-guided PENG phenol neurolysis using 10 mL of 10% nonglycerinated phenol, with six-week follow-up. Assessments were performed at baseline, 10 minutes, 24 hours, and Weeks 1, 2, 4, and 6 using validated measures: pain intensity (Visual Analog Scale [VAS]), neuropathic pain (Douleur Neuropathique 4 [DN4]), opioid consumption (oral morphine milligram equivalents [MME]), and function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]). Adverse events were predefined as new motor deficit, persistent sensory loss, infection, bleeding, or vasovagal reaction, and were monitored with serial neurochecks for 4 hours postprocedure and at each follow-up through Week 6.

Results: All patients-bedbound at baseline with VAS 10/10-experienced rapid and marked analgesia, with VAS scores of 1-2 within 10 minutes and sustained relief through six weeks. DN4 scores fell below the diagnostic threshold (≤3) in all cases. Daily opioid consumption decreased by 47%-77%, and all patients achieved assisted ambulation within 24 hours. No motor weakness occurred; the only adverse event was mild, transient anterior-hip hypoesthesia.

Conclusion: Ultrasound-guided PENG phenol neurolysis (10% phenol) may be a valuable motor-sparing option for refractory cancer-related hip pain in selected palliative care patients. These preliminary findings warrant evaluation in larger, controlled studies.

Context: End-of-life (EOL) discussions are of utmost importance to emergency medicine physicians, and residency programs vary in their training on this subject, despite being an Accreditation Council for Graduate Medical Education requirement.

Objectives: The primary objective of this work was to improve resident familiarity by delivering bad news to patients and/or families in time of critical illness and/or EOL discussions. The secondary objective was exposure to interpreting living wills and physician orders for life-sustaining treatment, which previous data from our department indicated that residents are generally unfamiliar with.

Methods: During two yearly sessions, emergency medicine residents received training on EOL discussions. Each session included a seminar on how to approach the delivery of difficult news to patients and families and how to engage them in conversation. Before and after each seminar, participants were asked to complete an online survey regarding experience, current comfort with EOL discussions, and demographics.

Results: While there was a minor increase in self-reported confidence in EOL conversations among first- and second-year residents after training sessions, third-year residents did not see this benefit. There was no statistically significant presession to postsession change in comfort level for any postgraduate year. Only in presurveys was there a statistically significant increase in overall confidence as residency year increased both in delivering the news that a loved one has died (P < 0.001) and in discussing the withdrawal of care (P = 0.01). While no specific questions showed significant improvement in postcurriculum, general participant feedback indicated that these sessions were meaningful and beneficial additions to their residency curriculum.

Conclusion: Our novel curriculum increased self-reported confidence in discussing EOL issues, especially among first- and second-year emergency medicine resident physicians. Training and experience with EOL conversations not only helps residents but ultimately benefits patients and their families.

Background: Withdrawal of Life Sustaining Therapies (WOLST) is a critical procedure in up to 50% of inpatient pediatric deaths. No best practice guideline (BPG) exists. We aimed to develop and implement a BPG and standard note template for WOLST procedures.

Measures: The smart aim was to increase use of the tools by 20% within 6 months. The measures were the percentage of tools used (process), usefulness of the tool (outcome), and narrative responses to identify unintended consequences (balance).

Intervention: PDSA cycles include engagement of stakeholders to create the tools, BPG distribution, and presentations to intensive care units.

Outcomes: Of those who used the tools, 100% found the note helpful and 95% found the BPG helpful. 65% and 78% of respondents reported not knowing about the note template or BPG, respectively.

Conclusion/lessons learned: Implementation of a BPG in pediatric WOLST procedure is feasible and helpful when used. Future work includes improved dissemination of the tool.

Context and objectives: Integrative oncology (IO) programs are being implemented in supportive and palliative cancer care services worldwide, though research on the design of IO training programs is limited. This paper explores perspectives of trainees undergoing a national, multi-disciplinary IO training program in Israel, through their pre- and post-training narratives.

Methods: Trainees underwent a 110-hour IO training program focused on symptom management, through online and in-person instruction. Qualitative analysis was performed on the written narratives of program trainees, addressing pretraining expectations and post-training outcomes. A digital questionnaire with open-ended questions was used, with free-text reflective narratives analyzed using ATLAS.Ti software for systematic coding.

Results: Of the 68 trainees participating in the program, 62 provided precourse assessment; and 44 completed training, of which 33 provided post-training narratives. Pretraining themes included an expectation for enhancing communication-related competencies, primarily with patients but also with other healthcare professionals. Post-training narratives highlighted themes which included forming a professional identity as IO providers; enhanced collaboration within multidisciplinary teams; acquisition of practical competencies across diverse IO modalities; sharing clinical strategies and knowledge; and experiences of both personal and professional growth.

Conclusions: Trainees in this national multidisciplinary IO training program expressed pretraining expectations focused primarily on communication skills; and post-training reflections emphasizing professional development, team-based practice, and integration of IO into palliative care. These findings suggest that IO training supports the transition from theoretical learning to practical clinical competencies. Further research is warranted to evaluate long-term symptom management and communication-related outcomes of combined IO and palliative care programs.