Journal of palliative medicine最新文献

Objectives: To identify differences in the number and characteristics of patients who completed a Medical Durable Power of Attorney (MDPOA) form through the patient portal during the COVID-19 pandemic compared to pre-pandemic. Methods: Data, including portal-based MDPOA forms, were extracted from the electronic health record at one U.S. institution (July 2017-May 2023). The pandemic period was defined as March 26, 2020, or after. Results: 397,682 patients added an MDPOA form during the study period. There was an increase in the proportion of portal-based MDPOA forms from 4.6% pre-pandemic to 5.1% during the pandemic (p < 0.001). Patients who used the portal to complete the MDPOA form during the pandemic were younger (p < 0.001) and had fewer comorbidities (p < 0.001) compared to pre-pandemic patients who completed a portal-based MDPOA form. Conclusion: MDPOA completion is important for patients of all ages and health statuses. Having MDPOA tools within a patient portal can support uptake among younger, healthier populations.

Context: The clinical characteristics of terminal dyspnea, including opioid effects, adverse events, and outcome acquisition rates, remain largely unexplored. Objectives: To investigate the clinical characteristics of terminal dyspnea in patients with cancer starting regular systemic opioid therapy, classified by clinician-predicted prognosis (days, weeks, months). Methods: This secondary analysis of a multicenter, prospective, observational study included adult patients with cancer who began regular systemic opioid therapy for dyspnea at 12 palliative care sites in Japan. Patients were classified into three prognostic groups: days (1-14 days), weeks (15-56 days), and months (>56 days) according to clinician-predicted survival [CPS]. Dyspnea intensity (numerical rating scale [NRS], Integrated Palliative care Outcome Scale [IPOS]) was assessed every 24 hours for 3 days. Adverse events and outcome acquisition rates were also evaluated. Results: A total of 402 patients were enrolled (days: 186, weeks: 174, months: 42). NRS and IPOS scores significantly improved across all groups. At 72 hours, mean NRS decreased from 7.2 to 4.5 in the days group, 6.5 to 3.9 in the weeks group, and 5.8 to 3.2 in the months group (p < 0.001 for all). Mean IPOS showed similar reductions. Somnolence and delirium increased in the days group, whereas such trends were not observed in the other groups. NRS acquisition rates declined in the days group (73.1-55.2%) but remained high in the weeks and months groups. IPOS acquisition rates were consistently high across all groups. Conclusion: Opioids alleviate dyspnea in patients with cancer regardless of CPS, but persistent symptoms remain. In imminently dying patients, adverse events were common and NRS was often not assessable. Further research should be conducted to optimize the assessment and management of patients with terminal dyspnea.

Background: Serious illness conversations are an iterative, interprofessional, team-based process that includes recommendations about medical care. Yet, it is not clear how clinicians in different role groups work together in this process. Objectives: We sought to examine how interprofessional clinicians in the medical intensive care unit (MICU) who were trained in the serious illness care program (SICP) document recommendations after serious illness conversations. Design: This is a retrospective chart review and inductive content analysis. Settings/Subjects: We reviewed the charts of patients admitted to the MICU of an academic hospital with a long history of palliative care (PC) in the northeastern United States between January 1 and December 31, 2019, who had at least one documented serious illness conversation. Results: Of the 207 conversations identified, 177 (85.5%) included a recommendation: 44.6% (79/177) were documented by registered nurses, 36.7% (65/177) by physician trainees (internal medicine residents and pulmonology/critical care fellows), and 18.6% (33/177) by PC consultants (physicians, nurse practitioners, and PC fellows). Recommendations were categorized into several domains: (1) code status (2) treatment interventions, (3) psychosocial support, and (4) communication. The recommendations textbox was also used to document general updates and patient education. The most common domains documented were code status and treatment interventions, respectively: Registered nurses (40.5%; 20.3%), physician trainees (52.3%; 36.4%), and PC clinicians (42.4%; 32.3%). Clinicians used the direct/active voice to document recommendations concordant with their scope of practice and the reporter/passive voice to document recommendations given by others. Conclusions: SICP-trained interprofessional MICU clinicians commonly give and document recommendations on a range of domains and flexibly use direct/active and reporter/passive voice to signal their scope of practice.

Background: Child loss is a grief population that requires specialized attention to the importance of legacy to the grieving process. Local Problem: Lack of pediatric hospice throughout the state led to a gap in psychosocial end of life (EOL) and bereavement care for families opting to have their child's EOL at home with hospice services. Methods: A pilot program was created to explore parents' experiences with memory-making kits (MMKs) while their child was on home hospice and its impact in their bereavement. Intervention: Families and their pediatric palliative care team could opt-in to a questionnaire to offer feedback on the MMKs. Results: Health care providers (HCPs) appeared to find benefit in the intervention and wished to continue to offer the MMKs to future families with additional suggestions around the introduction of the MMKs and prognostic criteria. Parental feedback is ongoing. Conclusions: The initial pilot implementation of these MMKs received overall positive feedback from HCPs. Further data exploration can continue to expand upon the MMKs' impact on the familial grief process and adult hospice providers caring for pediatric patients.

Background: Gastric cancer is frequently diagnosed at an advanced stage and is associated with high symptom burden. Palliative care can enhance quality of life, provide symptom relief, and support end-of-life planning. However, disparities in access may lead to inequitable care, particularly among vulnerable populations with advanced diseases such as gastric cancer. Methods: We conducted a retrospective cohort study using the National Inpatient Sample (2016-2020), a nationally representative database of U.S. hospitalizations, to identify predictors of palliative care utilization and its impact on outcomes among gastric cancer patients who died during hospitalization. Multivariable regression models assessed associations with length of stay (LOS), hospital charges, and intensive interventions. Results: Among 13,435 weighted hospitalizations ending in death, 57.6% received palliative care. Black patients had 32% lower odds of receiving palliative care than White patients (aOR: 0.68, 95% CI: 0.54-0.82). Higher palliative care use was associated with greater income, large hospitals, urban teaching hospitals, and private/other insurance. In adjusted analyses, palliative care was linked to a $36,240 reduction in hospital charges (95% CI: -$51,506 to -$20,974, p < 0.01), with no significant difference in LOS. Palliative care was associated with higher odds of DNR status (aOR: 4.77, 95% CI: 3.99-5.70, p < 0.01) and lower odds of CPR, mechanical ventilation, transfusion, and vasopressor use. Conclusion: Palliative care among hospitalized gastric cancer patients in the United States was associated with less intensive care and lower costs without prolonging LOS. However, significant disparities by race, income, insurance, and hospital type persist. Efforts are needed to ensure equitable access to inpatient palliative care at the end of life.