The American journal of hospice & palliative care最新文献

BackgroundPalliative care is highly relevant to acute care surgery due to the patient populations and severity of illness. Efforts to routinely incorporate palliative care principles in the practice of acute care surgery by the primary surgical team may benefit patients and their families.MethodsWe present a narrative review of the literature examining the current state of incorporation of primary palliative care in acute care surgery, including basic principles and strategies, evolving approaches, limitations, and opportunities for growth.ResultsImplementation begins with early identification of patients who may benefit from primary palliative care. Primary palliative interventions may include medical symptom management, patient and caregiver support, and use of frameworks for communication in the setting of severe illness. Significant barriers to primary palliative care practice exist, including institutional differences in approaches to primary palliative care, socioeconomic and cultural factors, and varying patient and clinician perspectives about the role of primary palliative care. Over the last few decades, there has been increased awareness of a role for primary palliative care in acute care surgery, leading to recent advances in quality, education, and advocacy.ConclusionsDespite the known benefits of primary palliative care, it is still underutilized in acute care surgical patients. Shifting attitudes toward primary palliative care are helping to increase its use in surgical settings as well as promote education for surgical trainees. However, it is important to recognize the many opportunities for improvement of primary palliative care incorporation in acute care surgery.

Promoting autonomy in medical decision-making is an essential part of palliative care. Therefore, palliative care providers should prioritize supporting the autonomy of sexual and gender minority (SGM) older adults, a community that has historically suffered from healthcare disparities. This support is particularly significant when an illness or injury renders a patient unable to make medical decisions, necessitating the designation of a surrogate decision-maker. Surrogate decision-maker policies vary by state and largely do not represent patients whose support systems are outside of the biological family. This article reviews healthcare disparities experienced by SGM older adults, including higher rates of certain health conditions and barriers to accessing care due to stigma and discrimination. It also highlights the compounded challenges faced by SGM individuals who are part of racial and ethnic minority groups. The lack of inclusive surrogate decision-making policies exacerbates these disparities, as many SGM older adults do not have legally recognized partners or children to act as decision-makers. The absence of inclusive policies for surrogate decision-making results in distress for patients, families, loved ones, and medical providers. This article discusses the importance of advance care planning and completion of advance directives for this population to ensure patient wishes are respected. Palliative providers need to advocate for surrogate decision-maker policies that are more inclusive of families of choice.

BackgroundTraumatic brain injury (TBI) often requires decisions about withdrawal of life-sustaining therapy (WLST). Palliative care consultation (PCC) plays a central role in facilitating these decisions, yet the impact of family-clinician communication on WLST remains underexplored. We aimed to examine predictors of WLST, particularly focusing on documented family-clinician interactions prior to PCC.MethodsWe conducted a retrospective cohort study of patients with TBI admitted to a unified health system between 2016 and 2022 who received both neurosurgical consultation and PCC. The key exposure included the number of documented family-clinician interactions prior to PCC. Multivariable logistic regression and LASSO regression were used to assess associations with WLST while adjusting for potential clinical confounders including injury severity and treatment intensity.ResultsAmong 228 patients with TBI (median age 81 years, 53% male), 51% (N = 117) experienced WLST. A greater number of documented family-clinician interactions prior to PCC was associated with lower odds of WLST (adjusted OR, 0.95; P = .02). LASSO regression confirmed documented number of family-clinician interactions, as well as radiographic midline shift, as independent predictors.ConclusionsFamily engagement may be associated with WLST decisions in patients with TBI eventually receiving PCC, as increasing documented family-clinician communication prior to PCC was associated with reduced likelihood of WLST. Although this study does not establish causation, it raises the hypothesis that more frequent family communication may influence goals-of-care decision-making independently of clinical severity and merits prospective evaluation.

Hospice provides comfort care to patients at end of life. Survival of patients in hospice shows considerable variation. Using a large national database of hospice patient data from 2015-6 we perform a descriptive analysis and examine this variation, and associated factors. In our secondary analysis of 472,196 patients enrolled into hospice, we found a median duration of survival of less than 4 weeks, although approximately ten percent of patients survive longer than 6 months, the duration that CMS sets as the maximum survival prognosis for admission to hospice. Among the 4 drug classes (analgesic, anxiolytic, anti-nausea and laxatives) recognized by CMS as appropriate for hospice patients only 4% of patients had no prescriptions in these classes. Analgesic use rose steadily across the hospice episode, particularly near death. The variation in survival among patients and the frequency of survival in excess of 6 months points to the need for more accurate predictive models and an opportunity to employ statistical analysis for hospice admission.

Hospice and palliative care are often hard to access for African Americans (AA) living in rural areas with serious respiratory illnesses. These services can improve symptoms, quality of life, and support for caregivers, but barriers remain. Under the Medicare Hospice Benefit, patients must stop curative or life-sustaining treatments for their terminal illness, which limits options for concurrent care. This is a major challenge for AA men, whose average life expectancy is 67.8 years-about 10 years shorter than the national average. They also experience more care transitions in the last 6 months of life compared to White and Hispanic patients. These frequent transitions show how fragmented the health system is and how it often fails AA families. Using intersectionality and a vignette, this paper explores how overlapping factors-lived experience as AA man, rural location, and serious illness-affect access to palliative care. The discussion ends with recommendations for clinical practice and public policy to reduce inequities and improve care.

BackgroundHome-based palliative care (HBPC) is increasingly recognized as an essential strategy for managing patients with non-oncologic and life-limiting conditions. However, prognostic factors influencing survival in this population remain underexplored.ObjectivesTo evaluate the prognostic impact of the Palliative Performance Scale (PPS) and comorbidities on survival among non-oncologic patients receiving HBPC in Brazil.MethodsA retrospective cohort study was conducted, including 248 non-cancer patients enrolled in a publicly funded HBPC program in Caratinga, Brazil. Sociodemographic data, comorbidities, and PPS scores at admission were extracted from medical records. Survival analyses were performed using Kaplan-Meier curves and Cox proportional hazards models, with model discrimination assessed by Harrell's C-index.ResultsDiseases of the nervous system (DNS) were the most frequent referral diagnoses (32.3%). Median survival was 78 days (95% CI: 46.0-98.0) for patients with DNS and 34 days (95% CI: 19.0-50.0) for those without (P = .014). In multivariate analysis, DNS (P = .0157) emerged as the strongest predictor of survival, whereas PPS at admission (P = .0629) was a weak predictor (model C-index = 0.60). Patients with Alzheimer's disease and related dementias demonstrated longer survival than those with other DNS or no DNS diagnoses (P < .014). Higher PPS scores were generally associated with longer survival, although predictive accuracy was limited.ConclusionsDNS conditions, particularly dementia, were associated with longer survival among non-oncologic HBPC patients. While PPS remains a useful tool, its discriminatory capacity was modest, underscoring the need for refined prognostic models in non-oncologic palliative care.

BackgroundPrior research has examined the impact of limited English proficiency (LEP) in the hospital setting at the end of life in select regions of the United States.ObjectiveExamine whether LEP is associated with bereaved family ratings of quality of care in a national survey.DesignSecondary data analysis of the National Health and Aging Trends Study (NHATS).Setting/ParticipantsNational sample of bereaved respondents.MeasurementLast month of life survey about quality of care with decedents. Decedents classified as LEP based on need for translator, proxy use due to limited ability to speak English, and/or interview rating of understanding English. Multivariate regression model examined the overall association and interaction of LEP and Hispanic heritage after adjustment for socio-demographic, diagnoses, bereaved respondent relationship with decedent, and functional decline.ResultsOf 17.1 million deaths, 5.4% occurred in Hispanic decedents, compared to 3.0% among non-Hispanics (P ≤ .001). The strongest disparity was a 12.9-point lower adjusted quality-of-care rating for Hispanic decedents with LEP (65.6, 95% CI 55.3-76.1) compared with non-Hispanic decedents without LEP (78.5, 95% CI 77.5-79.6). These ratings were also lower than those of non-Hispanic decedents with LEP (84.1, 95% CI 74.0-94.4) as well as Hispanic decedents without LEP. Significance was determined by non-overlapping CIs. Respondents of Hispanic decedents with LEP reported trends of higher unmet needs for dyspnea palliation and receipt of goal concordant care.ConclusionLEP is prevalent in Hispanic decedents, with those with LEP reporting lower ratings of the quality of care compared to non-Hispanics without LEP.

IntroductionCancer is one of the leading causes of global mortality and imposes high costs on healthcare systems. In Brazil, a significant portion of resources is allocated to oncology, especially in the terminal phase. Palliative care has been associated with reduced hospital expenses and improved quality of life. This study aimed to compare direct medical costs in the last week of life of oncology patients receiving usual care (UC) or palliative care (PC).MethodsA retrospective cohort study conducted at Santa Rita Hospital (Porto Alegre, RS), using data from 2021. Patients over 18 years old, hospitalized for ≥7 days, whose death resulted from cancer progression, were included. The sample comprised 58 individuals: 41 in PC and 17 in UC. Direct medical costs included medications, procedures, laboratory and imaging exams, adjusted for inflation and converted to US dollars.ResultsDespite no statistically significant difference in the median of total cost (P = 0.4493), the median cost was lower in the PC group (USD 67.5) compared to the UC group (USD 91.5). Patients receiving palliative care had reduced costs related to procedures, laboratory tests, and imaging exams.ConclusionThe integration of palliative care was associated with reduced specific expenses and greater multidisciplinary support, indicating potential for resource optimization in oncology. These results reinforce the importance of systematic incorporation of this approach in the Brazilian context.

BackgroundGoals-of-care (GOC) discussions align medical treatment with older adults' preferences, yet are hindered by communication barriers, provider discomfort, and misinformation. Video-based decision aids improve understanding and reduce decision conflict, though data on their use in older populations remain limited. This review aimed to determine the effectiveness of video-based decision aids in improving GOC discussions and decision-making outcomes among older adults.MethodsFor this systematic review, a medical librarian conducted a literature search of Medline, Embase, Web of Science, CINAHL, PsychINFO, and Cochrane from database inception through April 2025. Eligible studies evaluated a video-based aid in US adults aged ≥65 years to facilitate GOC or code status decisions. The Cochrane Risk of Bias tool was used to assess quality of randomized, interventional studies.ResultsOf 4438 identified studies, 7 underwent full review, and 5 met inclusion criteria. Among inpatient settings, 2 studies found video interventions significantly increased patient preference for comfort-based care, while another using a shorter video, found no effect. In outpatient settings, one study found increased preference for comfort-based care with video intervention, while another reported no preference differences. Two studies assessed knowledge; one inpatient study found no change, while an outpatient study reported greater end-of-life knowledge in the intervention group. Video variability and differences in measured outcomes limited comparisons and generalizability.ConclusionsVideo-based decision aids show promise for improving knowledge and aligning treatment preferences. Further studies are needed to investigate the impact of video-based decision aids on GOC conversations in older adults in acute care settings.

ContextDespite efforts to incorporate more palliative and hospice topics into medical education, research indicates that gaps in sufficient formal education and student experience remain.ObjectivesFollowing a recent curricular redesign, the authors sought to evaluate the self-reported knowledge and confidence of our institution's fourth-year medical students regarding primary palliative care skills. Open-ended responses revealed that students desire more enhancements to palliative and hospice medical school curricula.MethodsBased on survey results, the authors developed and implemented a two-hour high-yield skills simulation session on core palliative skills. Paired pre- and post-session surveys were analyzed. ResultsPost-session, students reported significantly increased confidence in performing many primary palliative care skills, including delivering serious news, discussing code status, and explaining hospice care to patients.ConclusionWith only 2 h of student and faculty time, this simulation-based learning event offers a practical and effective approach to enhancing students' understanding and readiness to engage in palliative care practices.