The American journal of hospice & palliative care最新文献

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.

BackgroundBowel obstruction in the setting of peritoneal metastases is a complex clinical situation. Evidence for operative intervention in this setting remains unclear. This study aimed to compare outcomes between patients with bowel obstruction and peritoneal metastases who underwent operative intervention vs those who underwent conservative management.MethodsThis was a retrospective single center study of all patients that were consulted on by the Division of Colon and Rectal Surgery in the 6-year period between January 1st 2019 and December 31st 2024 for the management of bowel obstruction in the setting of peritoneal metastases. The study compared patients who underwent operative intervention vs those who underwent conservative management. The primary outcome measures were ability to tolerate solid food at discharge, median obstruction free survival, and median overall survival.ResultsA total of 100 patients were diagnosed with bowel obstruction in the setting of peritoneal carcinomatosis. 47 patients underwent operative intervention and 53 underwent non-operative management. Those who underwent operative intervention were more likely to tolerate solid food at discharge (78.72% vs 47.17%, P < 0.01) and had a longer median obstruction free survival (593 days vs 147 days, P = 0.01). No difference was identified in overall survival (133 days vs 99 days, P = 0.49).ConclusionsBowel obstruction in the setting of peritoneal metastases is a complex situation that requires a personalized and pragmatic approach for each patient. Selecting those who may benefit from operative intervention can be challenging, however, there are subsets of patients for whom surgical management may be offered with acceptable outcomes.

PurposeThere is emerging evidence that music therapy (MT) is an effective tool within palliative care to manage patients' complex needs. This performance improvement project aimed to assess palliative care staff members' attitudes toward the current utilization of MT within the institution's hospital-based interdisciplinary practices.MethodsEighty-four staff members practicing within hospital-based palliative care teams were invited to complete a voluntary anonymous mixed methods survey about their impressions of current MT integration. Survey questions inquired about reasons for MT referral, most common pertinent symptoms, perceived benefit to patients, future suggestions for growth, unexpected experiences, and perceived personal benefit to staff.Major FindingsFifty-one staff members (61%) responded. Top reasons for MT referral were psychosocial support, pain and symptom management, and coping. The most common symptom-focused indications were anxiety, mood, and existential distress. A variety of factors influenced decisions to refer for MT. Most felt that at least half of their patients could benefit from MT, and nearly all rated MT as "extremely" or "very" effective for improving patients' quality of life. Suggestions for potential growth for MT in palliative care in the future centered on themes of greater availability, increased variety and collaboration, research opportunities, and staff members' desire to receive more exposure to MT.ConclusionsIn this single-institution performance improvement project, staff attitudes were highly favorable toward MT for palliative care patients. MT is utilized for a variety of reasons, can be highly effective for improving patients' quality of life, and may also be of direct benefit to staff.

ObjectiveTraumatic stress among families of critically ill patients is common and associated with interpersonal conflict between families and intensive care unit (ICU) clinicians. This qualitative study aimed to characterize clinician documentation of family members with high levels of traumatic stress in the electronic health record (EHR).MethodsMechanically ventilated patients with surrogate decision makers reporting a Post-Traumatic Stress Symptoms Scale score >35 (consistent with post-traumatic stress disorder) were included. All electronic notes from patients' ICU stays were included. Thematic analysis used a structured codebook focused on surrogate behaviors, relationships, and coping strategies; resources provided to surrogates; and medical decision making.ResultsTwenty-five surrogates were largely female (n = 22, 88.0%) and had a median age of 48 years (interquartile range [IQR] 41-55 years) and median PTSS-10 score of 46 (IQR 38-53). Most of their critically ill loved ones (n = 17, 68%) survived the hospitalization. Three major themes emerged: (1) documentation of surrogate traumatic stress was inconsistent unless it disrupted clinical care; (2) surrogate-clinician conflict and goal misalignment intensified surrogate distress; and (3) multidisciplinary team members were crucial for providing emotional support and bridging communication.ConclusionThese findings suggest the need for standardized approaches to identify and address surrogate traumatic stress in the ICU. Investment in multidisciplinary teams is also essential-not only to ease surrogate distress but also to facilitate trust, communication, and collaborative decision-making. Investing in these resources and bringing awareness to how our documentation can perpetuate stigma are key steps toward reducing re-traumatization and advancing person-centered care in the ICU.

AimsTo explore whether intention, knowledge, contemplation, self-efficacy, and readiness related to advance care planning change over time following advance care planning education, and to examine how sociodemographic factors help predict engagement in advance care planning among community-dwelling adults.DesignA quasi-experimental, one group, pre-test, post-test study was conducted with 78 community-dwelling adults in the United States between November 2024 and March 2025.MethodsThe validated Advance Care Planning Engagement Survey measured intention, knowledge, contemplation, self-efficacy, and readiness at baseline, 2-weeks, and 3-months following use of The Conversation Project Starter Guide. Sociodemographic predictors included age, race, gender, marital status, education, employment, insurance, chronic illness, and zip code. Data were analyzed using descriptive statistics, repeated measures ANOVA, chi-square, and binary logistic regression.ResultsAdvance care planning education positively influenced both the intention to engage (commitment to making a change soon) and readiness to engage in advance care planning among community-dwelling adults. The Conversation Project Starter Guide had a significant impact on intention to engage scores over time, with the most dramatic change observed between baseline and 2-weeks post-education. Chronic illness was a significant predictor of advance care planning engagement among community-dwelling adults.ConclusionFindings suggest that implementing advance care planning education may positively enhance engagement in awareness and readiness to engage in advance care planning.

BackgroundMost older adults in the U.S. visit the emergency department (ED) in their final 6 months of life, providing an opportunity to engage patients in advance care planning (ACP) conversations (ie, a process to formulate and communicate preferences for end-of-life care). While many report ACP engagement, the link between self-reported engagement and pre-existing ACP documentation in the ED, where ACP documentation is especially critical, remains unclear.MethodsThis cross-sectional study is a secondary analysis of the VIDEO-ED trial, a multi-site randomized controlled study evaluating a video-supported ACP intervention in the ED. Patients aged ≥65 years and adults with serious illness (ie, illnesses with a 1-year prognosis) were prospectively enrolled. ACP engagement was measured using the validated ACP Engagement Survey. Medical records were reviewed for ACP documentation, including clinician-documented ACP and advance directives.ResultsAmong 570 participants (median age: 73.0 years, IQR: 68.0-79.0), higher ACP engagement scores were associated with greater clinician-documented ACP (OR: 1.47, 95% CI: 1.09-1.98, P = 0.01) and advance directives (OR: 1.40, 95% CI: 1.15-1.71, P < 0.01). Readiness to sign official documents naming a medical decision-maker was particularly predictive of ACP documentation (OR: 1.42, 95% CI: 1.03-1.97, P = 0.03).ConclusionsOn ED presentation, patient-reported ACP engagement correlated with the presence of pre-existing ACP documentation in the EHR. The ACP Engagement Survey may help identify older adults less likely to have documented ACP, guiding targeted interventions in the ED.

This study aims to determine whether the timing of a VitalTalk communication workshop during the academic year affects internal medicine residents' confidence and stress in serious illness conversations (SICs), and to assess differences by postgraduate year (PGY). It is a single-center, community hospital, retrospective pre-/post-test survey design. Thirty-six medicine residents (PGY1-3+) participated in mandatory half-day VitalTalk workshops delivered in the fall, winter, or spring. Surveys assessed self-perceived confidence and anticipatory stress regarding SICs, breaking bad news, and goals-of-care discussions using 11-point Likert scales. Paired sample t-tests compared pre- and post-workshop responses; one-way ANOVA compared gain scores across PGY levels and cohorts. Across all participants, confidence in SICs increased significantly after the workshop (mean change +1.21, P < 0.01), with improvements observed across all PGY levels and cohorts. No significant differences in confidence gains were detected between groups. Anticipatory stress did not change significantly overall; however, PGY2 residents experienced a significant reduction in stress for both goals-of-care (mean change -1.27, P = 0.015) and breaking bad news (mean change -1.45, P = 0.007). We conclude that the timing of a communication workshop within the academic year was not associated with changes in confidence or stress among all residents. Among graduate years, PGY2 residents showed the most significant stress reduction. These findings suggest there is no association between confidence, stress, and the timing of a SIC VitalTalk workshop during the academic year. PGY2 residents reported the greatest stress reduction from this workshop, suggesting that this year may be the optimal time to introduce a novel communication curriculum.