The American journal of hospice & palliative care最新文献

Background: All physicians encounter patients with serious illness. Medical students recognize the value of hospice and palliative medicine (HPM) and desire more knowledge and skills in this area. However, both pre-clinical and clinical HPM content are underrepresented within medical school curricula. Objectives: To conduct a pilot study examining the impact of a novel required HPM clinical experience on pre-clinical medical and dental students' learning through mixed methods evaluation of student responses. Design: Students completed a two-part electronic survey following a half-day HPM mentored clinical shadowing experience (HPM-MCSE) which included an introductory session, a faculty-mentored shadowing experience and a debriefing session. Setting/subjects: 163 first-year students at Harvard Medical School in Boston, Massachusetts, USA in 2022. Measurements: The survey collected demographic information and student responses to both closed-ended (Likert-scale) and open-ended prompts. Data were analyzed quantitatively using descriptive statistics and qualitatively using constant comparative methodology. Results: 127 medical and dental students responded (78% response rate). Qualitative analysis yielded three overarching themes: acquisition of knowledge about operational dimensions of HPM, acquisition of knowledge about psychosocial dimensions of HPM, and personal impact including an awareness of discordance between expectations and lived experience of HPM practice. Of the 109 students who completed the entire survey, 67% indicated that this experience increased their interest in palliative care and 98% reported an increase in their understanding of how palliative care enhances patient care. Conclusions: Early clinical exposure to HPM for first year students stimulates multi-dimensional learning about HPM and evokes personal reflection about serious illness care.

Objectives: A significant proportion of adults admitted to hospital are in their last year of life. We evaluated admissions for these patients.

Methods: We identified ambulance callouts to patients known to the palliative care team. Data collected included admission outcome (e.g. discharge or death).

Results: There were 162 ambulance callouts between 126 patients known to the palliative care team. 8 patients (6%) died within 72 hours of admission.

Conclusion: Our data suggests many palliative care patients can be appropriately treated in the community.

Background: Dialysis is often initiated in the United States without exploring patients' preferred decision-making style, and conservative kidney management (CKM) is infrequently presented. To improve kidney therapy (KT) decision-making, research on nephrologists' comfort with various decision-making styles, attitudes towards CKM, and reports of patients' lived experiences with KT decision-making is needed.

Methods: We surveyed 28 nephrologists and 58 of their patients aged ≥75 years. The nephrologist survey was designed to gauge their comfort levels with decision-making styles and attitudes towards CKM. The patient survey assessed experiences in making KT decisions.

Results: The average age of nephrologists was 43 years, and that of patients was 82 years. Nephrologists rated themselves as comfortable with various decision styles: paternalistic (60.7%), shared decision-making (92.8%), and patient-driven decision-making (67.8%). Nearly 57% of nephrologists felt challenged or were neutral in determining CKM's suitability, and 39% reported difficulties in discussing CKM with patients or were neutral. Only 38 % of patients recalled discussing CKM with their nephrologists, and a minority reported discussing CKM-related topics such as life expectancy (24.7%), quality of life (QOL) (45.1%), and end-of-life care (17.5%).

Conclusions: Most nephrologists displayed comfort with various decision-making styles; however, many described difficulties in guiding patients toward CKM. In contrast, patients reported gaps in vital aspects of KT decision-making and CKM choices, such as discussions of life expectancy, QOL, and end-of-life care. Raising awareness of blind spots in decision-making skills and educating nephrologists in KT decision-making to include CKM and other person-centered aspects of care are needed.

Background: Due to an urgent need to develop palliative care services for geriatric patients with advanced cancer, an overview of available information regarding home-based palliative care interventions would be valuable.

Aim: To summarize current literature for interventions targeted to homebound, older patients with incurable cancer, and investigate whether these patients can be benefited from home-based palliative care and achieve improved outcomes.

Design: A search strategy consisting of terms related to home care, palliation, oncology, and geriatrics was employed. A protocol following PRISMA guidelines was prospectively uploaded at PROSPERO (ID = CRD42023404675).

Data sources: Pubmed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Epistemonikos.org databases were searched from inception until the present day. Eligibility criteria were selected based on the research question, the population of interest, and the research design. The Risk of Bias Assessment Tool version 2 (RoB-2) was used to appraise study quality.

Results: A total of 10 articles including 871 patients (out of 1236 titles and 141 fully-reviewed texts) were selected. Four studies assessed exercise interventions, two evaluated multi-component home-care models, two focused on supervision services, and two had nutrition and activity components. Eight studies reported improved outcomes in either specified or mixed cancer geriatric populations.

Conclusions: There is a scarcity of clinical trials regarding home-based palliative care for geriatric oncology patients, resulting in poor information and a lack of evidence. At-home interventions seem feasible and have a positive effect on pain management and functional status, but more high-quality studies are required.

Background: Optimal care for seriously ill and older patients often involves advance care planning (ACP), goals-of-care (GOC) conversations, and specialty palliative care consultation, three sometimes overlapping, yet distinct practices. Insufficient staffing and investment in these areas have limited their availability.

Objectives: We explored the facilitators and barriers to successful implementation of the VIDEO-PCE trial. The intervention aimed to increase patient engagement in ACP, GOC, and by establishing Palliative Care Educators, a new clinical role integrated into existing hospital wards.

Design: This qualitative interview study employed a semi-structured interview guide tailored to the interviewee's clinical role. The interviews elicited perceptions of the facilitators and barriers to integration of palliative care educators (PCEs) into existing workflows. We developed deductive codes a priori and inductive codes as we coded interview transcripts.

Setting/subjects: Medical/surgical floor clinical colleagues, palliative care team members, and PCEs from both participating sites were interviewed.

Results: Twenty-four individuals were interviewed (12 clinical staff of medical and surgical wards, seven palliative care team members, and five PCEs). Four themes were identified: (1) The work completed by the PCEs provided a foundation for future palliative care involvement; (2) Constituting the new role in practice required revision and creativity; (3) Communication was important to providing continuity of care; and (4) Establishing trust catalyzed the acceptance of the role.

Conclusion: The creation and implementation of a new role within existing clinical workflows posed some challenges but were felt to relieve staff from some work burden and allow more patients to engage in ACP and GOC conversations.

Trial registration: ClinicalTrials.gov Identifier: NCT04857060.

Objective: Information regarding the nutrition profile of advanced cancer patients followed at home is lacking. The aim of this study was to assess the nutritional status of patients who were admitted to specialized home palliative care, and examine eventual factors associated with malnutrition.

Design: Cross-sectional. Setting/subject: patients who were admitted to 2 specialized home palliative care programs.

Participants: A consecutive sample of patients admitted to home care was selected. Depression, anxiety, nausea, poor appetite, and poor well-being were measured by numerical scale 0-10. Mini nutritional assessment form (MNA-SF), fatigue assessment scale (FAS), and sarcopenia by SARC-F. were performed. The use of drugs used for anorexia, including corticosteroids, progestins, or others, was recorded.

Results: Data of 135 patients were analyzed. Sixty-eight per cent and 77% of patients resulted to be malnourished and sarcopenic. In the multivariate regression analysis, anxiety (P = 0.036) and total FAS (P = 0.013) were independently associated with malnutrition. Fifty-five per cent of patients were receiving corticosteroids or megestol acetate. No significant associations with parameters examined were found.

Conclusion: The majority of advanced cancer patients admitted to home palliative care were malnourished independently of the primary tumor diagnosis. Indeed, fatigue and anxiety were independently associated with malnutrition.

Background: The largest patient group initiating dialysis for end-stage renal disease is persons over 75 years. Evidence indicates pre-dialysis shared decision-making discussions between nephrology providers and older adults are infrequent and often do not include an option for conservative management of symptoms without dialysis. Aims: To assess and compare behavioral determinants of nephrology providers' use of comprehensive pre-dialysis shared decision-making discussions with older adults. A secondary aim was to prepare the bases for tailored behavioral intervention(s) for nephrology providers by identifying the determinant(s) that should be targeted to elicit change in comprehensive shared decision-making intentions and the resulting behavior. Methods: A cross-sectional survey based on the Theory of Planned Behavior was completed by nephrologists from a state organization and nephrology advance practitioners from a national organization, either in person or online via Qualtrics. Results: Survey respondents included nephrologists (n=29), and nurse practitioners (n=37) and physician assistants (n=7), combined, were predominantly female (83%) and White American (67%). Spearman rho correlation results showed attitude, social norm, and perceived behavioral control were correlated with shared decision-making behavior for one or both groups. Significant differences were present between the two groups for determinants and behaviors. Conclusion: Based on the determinants predominantly influencing SDM behavior of nephrology advance practitioners, behavioral interventions targeting the determinants of Social Norm and Perceived Behavioral Control are warranted. All determinants can be utilized in behavioral interventions for nephrologists.Opportunity exists for collaboration between providers to develop consistent and effective methods of SDM discussion that fit into a typical workday.

Background: Hospice services for patients with Huntington's disease (HD) are likely beneficial in relieving significant burdens and minimizing costly hospitalizations at the end of life, though there has been little study or clinical guidance on hospice enrollment for patients with HD. Objectives: The primary objective of this study was to identify clinical, sociodemographic, and system-level factors associated with discharges to hospice compared to other dispositions for hospitalized patients with late-stage HD. Methods: These analyses used data from the Nationwide Inpatient Sample between the years 2007 and 2011. Weighted logistic regression with a forward selection approach was performed to identify factors associated with discharge to hospice compared to discharge to home, facility, other locations, and death in hospital. Results: These analyses included 6544 hospitalizations of patients with late-stage HD. There was a significant increasing trend in discharges to hospice over the study period (P < 0.001). After adjustment, multiple clinical, sociodemographic, and system-level variables were identified as being associated with discharges to hospice. Patients with aspiration pneumonia and non-aspiration pneumonias had lower odds of being discharged to hospice compared to dying in the hospital. When comparing to discharges to facilities and home, weight loss and palliative care consultation were associated with greater odds of discharge to hospice. Conclusions: Our findings serve as a foundation for future studies on these factors, and thus help clinician decision-making on when to start advance care planning or end-of-life care for patients with HD. These results also support studies developing hospice referral criteria specific to patients with HD.

Background: Existential experiences often come to the fore in the case of a severe and/or life-threatening disease and in old age. This can evoke a variety of thoughts and emotions. The existential dimension is a concept that encompasses spiritual, religious and secular perspectives. Objective: The aim of this study was to gain a deeper understanding of how patients describe the existential dimension of life and whether and in what way the existential questions are raised in conversations and other forms of support within care. Methods: A qualitative design, with in-depth semi-structured interviews with patients admitted to an out-clinic oncology department at one hospital and participants living in a nursing home. The interviews were analysed using qualitative content analysis. Results: A total of 15 persons were interviewed. The respondents varied in age from 44 to 96. Two main themes emerged: What are existential questions? and Talk about existential questions. The existential questions refer to life as a whole and death as an end of life. It was summarized into three subcategories: The experience of the life, Existing within context and Spirituality and religion. About half of the participants thought it was important to talk about existential questions. They wanted to choose who to talk to, when and about what. Support was received from loved ones, professionals and experiences beyond conversations. Conclusions: The study provide new knowledge of how patients and elderly experience the existential dimension. The respondents emphasized a desire to be selective with whom they shared these questions and thoughts.