PC-FACS

Abstract

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] . PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] . Song L, Wang H, Wang YJ, et al. Hippocampal PPARα is a novel therapeutic target for depression and mediates the antidepressant actions of fluoxetine in mice. Br J Pharmacol. [Published online ahead of print on May 3, 2018]. https://doi.org/10.1111/bph.14346. Black I, Helgason ÁR. Using motivational interviewing to facilitate death talk in end-of-life care: an ethical analysis. BMC Palliat Care. 2018;17(1):51. Ouchi K, Jambaulikar GD, Hohmann S, et al. Prognosis after emergency department intubation to inform shared decision making. J Am Geriatr Soc. [Published online ahead of print on March 15, 2018]. https://doi.org/10.1111/jgs.15361. Wachterman MW, Hailpern SM, Keating NL, Kurella Tamura M, O'Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med. 2018;178(6):792-799. AbuDagga A, Mara CA, Carle AC, Weech-Maldonado R. Factor structure of the cultural competence items in the National Home and Hospice Care Survey. Med Care. 2018;56(4):e21-e25. Fallon MT, Wilcock A, Kelly CA, et al. Oral ketamine vs placebo in patients with cancerrelated neuropathic pain: a randomized clinical trial. JAMA Oncol. 2018;4(6):870-872. Major depressive disorder is a leading worldwide health problem.1 Is hippocampal peroxisome proliferator-activated receptor α (PPARα) a potential antidepressant target? This study tested whether PPARα (a nuclear receptor protein that functions as a transcription factor and regulates genes) is involved in depression pathogenesis and antidepressant medication efficacy, and whether targeting PPARα may be a new approach for developing novel antidepressants. Various biotechnological methods were used to evaluate the effects of chronic stress and the selective serotonin reuptake inhibitor, fluoxetine (20 mg/kg intraperitoneally), on hippocampal PPARα. The viral-mediated genetic approach also was employed (via intra-hippocampal viral infusions to trigger PPARα overexpression) to explore whether hippocampal PPARα was an antidepressant target. PPARα inhibitors, PPARα-knockout mice, and PPARα-knockdown mice were further used to determine the role of PPARα in fluoxetine's antidepressant efficacy. Mice were exposed to behavioral stress tests, including forced swim, tail suspension, and the chronic social defeat stress procedure. One-way ANOVA with post-hoc LSD test and two-way ANOVA with post-hoc Bonferroni's test were used. Chronic stress decreased hippocampal PPARα mRNA and protein levels and fully reduced recruitment of hippocampal PPARα to the cyclic-AMP response element binding (CREB) promoter. Genetic overexpression of hippocampal PPARα induced antidepressant-like actions by promoting CREB-mediated biosynthesis of brain-derived neurotrophic factor. Moreover, fluoxetine reversed the stress-induced reduction effects on hippocampal PPARα. Pharmacological blockade of PPARα fully antagonized the antidepressant efficacy of fluoxetine, and both PPARα-knockout and PPARα-knockdown abolished the effects of fluoxetine. In addition, PPARα-knockout and PPARα-knockdown aggravated depression (all results P<0.01). Researchers present a series of elegant studies that support the role of PPARα in the pathogenesis of depression. Palliative care clinicians frequently manage clinical depression in patients with advanced illness and often recognize the limitations of pharmacologic agents, such as SSRIs, both in terms of efficacy and onset of clinical response. In the future, therapy-targeting hippocampal PPARα may allow us to see more immediate and improved response in patients with major depression, and the development of pharmacological PPARα agonists for the treatment of clinical depression alone or with traditional antidepressants is promising. However, enthusiasm for quick pharmacological “fixes” must be tempered in patients with advanced illness who often have multiple psychosocial factors, issues of demoralization, and existential distress contributing to altered mood. In an animal model, hippocampal PPARα mRNA and protein levels contributed to the pathogenesis of depression. Jacob J. Strand, MD FACP FAAHPM, Mayo Clinic Center for Palliative Medicine, Rochester, MN. Song L, Wang H, Wang YJ, et al. Hippocampal PPARα is a novel therapeutic target for depression and mediates the antidepressant actions of fluoxetine in mice. Br J Pharmacol. [Published online ahead of print on May 3, 2018]. https://doi.org/10.1111/bph.14346. 1.Hirschfeld RM. Depression epidemiology and its treatment evolution. J Clin Psychiatry. 2012;73(10):e29. A lack of preparedness for a loved one's death is a risk factor for secondary psychological morbidity among survivors.1 Can a motivational interviewing (MI) intervention aimed at facilitating death talk reduce “unprepared bereavement” (UB)? This paper evaluated the ethical permissibility of MI interventions in end-of-life care with the aim of facilitating death talk, either by the patient directly or by a health professional with the patient's consent, as a partial solution to UB. The authors suggest that the absence of death talk between patients and loved ones, or health professionals and loved ones, contributes to UB. They consider two ethical objections to using MI: first, that it is inappropriate for practitioners to seek disclosure of end-of-life diagnosis/prognosis as an outcome in this setting; second, that aiming at disclosure risks manipulating individuals into talking about death. MI-based interventions may be directional (the interviewer seeks a substantive outcome) or nondirective (no substantive outcome is sought). The authors submit that either directional or nondirective MI is ethically advantageous vs. unsystematic approaches as both modes facilitate physician-patient conversations about serious news and increase the likelihood that patients themselves will have a good death. The ethical concern about using MI as a manipulative technique suggests that it is ethically preferable to use MI nondirectively. However, since nondirective MI is more difficult to learn, the authors argue that it may be ethically permissible to employ directional MI (with disclosure of serious news as the target behavior). They conclude that MI interventions aimed at facilitating talk about serious illness, prognosis, and dying may be ethically permissible. This paper raises two major issues: 1) the idea of using MI to promote patients' disclosure of serious news to family members and 2) whether or not MI is ethical in such situations. The first issue is straightforward in patients who are ambivalent about disclosure. Because MI is a therapeutic technique for identifying barriers to behavioral changes, it seems logical that it could be of use in situations where resolving ambivalence is useful (but the therapist should be neutral to what the patient decides). The question of ethics is confused by the authors' description of MI as inherently “manipulative.” This is a mischaracterization of MI, which is patient-centered and nonjudgmental. The paper makes several empirically based claims—nondirectional MI is more difficult to learn and directional MI leads to “better conversations/deaths” than “unsystematic approaches”—without data. In addition, the utilitarian argument that it is ethical because it leads to better outcomes does not consider nonconsequential objections. MI may be useful for facilitating patient disclosure of serious news to family members, as long as it is done by well-trained providers with patients who are open to exploring their decisional ambivalence. Erin Zahradnik, MD, University of Chicago, Chicago, IL. Black I, Helgason ÁR. Using motivational interviewing to facilitate death talk in end-of-life care: an ethical analysis. BMC Palliat Care. 2018;17(1):51. 1.Barry LC, Kasl SV, Prigerson HG. Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death. Am J Geriatr Psychiatry. 2002;10(4):447-457. Emergency intubation of older adults will double 2001-2020.1,2 What are the in-hospital mortality and discharge dispositions for older adults intubated in the emergency department (ED)? This retrospective cohort study analyzed a large national dataset to ascertain in-hospital mortality and discharge dispositions for adults aged ≥65 intubated in the ED 2008-2015. Individual-level administrative data from Vizient, a consortium of >117 academic medical centers and >300 American hospitals, were used. Exclusions: trauma upon admission, out-of-hospital intubation, and cardiac arrest. The primary outcome was age-specific in-hospital mortality. Secondary outcomes were age-specific odds-of-death after adjusting for race, comorbid conditions, admission diagnosis, hospital disposition, and geographics. The Charlson Comorbidity Index (CCI),3 multivariable logistic regression, and the Hosmer-Lemeshow test were used. Participants (n=35,036) were 54% female, 64% non-Hispanic white, and 51% CCI ≥3. Seventy-five percent came to the ED from home, and 24% were discharged to home (median length-of-stay was 9 days [IQR=5-15]). In-hospital mortality was 33%, and median time-to-death was 3 days (IQR=1-8). Eighty-four percent of decedents died ≤10 days post-intubation. No variables were collinear (mean variance Inflation factor=1.01), and model fitness was appropriate (P=.22). Odds of death were 2.6 times higher when aged ≥90 (vs. 65-74; 95% CI=2.4-2.9). In-hospital death was 70% more likely when arriving from another hospital (vs. home; 95% CI=1.5-1.9). Odds of death were 1.5 times higher (95% CI=1.4-1.6) for those with CCI >4 (vs. 0). Cerebrovascular accident (OR=2.4, 95% CI=2.2-2.6) and sepsis (OR=1.5, 95% CI=1.4-1.6) were associated with greatest in-hospital mortality. Odds of dying in-hospital were 20% lower for African Americans (vs. whites) and 10% lower for Midwesterners (vs. Mid-Atlantic). Accurate prognostic information is central to shared decision making in advance care planning (ACP). Despite availability of general mortality prediction models,4 predicting outcomes for specific interventions in various settings is challenging. Emergency intubation risks long-term disability, an outcome many older adults choose to avoid even if faced with death.5 In this study, only 14% of those intubated in the ED survived and were discharged home. Strengths of this study include use of a large, broadly representative population. The authors also used a visual diagram to display outcomes after intubation, which may augment shared decision making6 as many adults have difficulty interpreting numerical data.7 A limitation was that discharge disposition is not a direct measure of functional status and does not indicate whether survivors were able to return home after nursing home stays. Age-specific prognostic information for emergency intubation adds to existing knowledge to provide more nuanced and accurate data for shared decision making. Elizabeth Chuang, MD MPH FAAHPM, Albert Einstein College of Medicine, Bronx, NY; Sarah Garijo-Garde, Vassar College, Poughkeepsie, NY. Ouchi K, Jambaulikar GD, Hohmann S, et al. Prognosis after emergency department intubation to inform shared decision making. J Am Geriatr Soc. [Published online ahead of print on March 15, 2018]. https://doi.org/10.1111/jgs.15361. 1.Lagu T, Zilberberg MD, Tjia J, Pekow PS, Lindenauer PK. Use of mechanical ventilation by patients with and without dementia, 2001 through 2011. JAMA Intern Med. 2014;174(6):999-1001.2.Mehta AB, Syeda SN, Wiener RS, Walkey AJ. Epidemiological trends in invasive mechanical ventilation in the United States: a population-based study. J Crit Care. 2015;30(6):1217-1221.3.Lagu T, Zilberberg MD, Tjia J, et al. Dementia and outcomes of mechanical ventilation. J Am Geriatr Soc. 2016;64(10):e63-e66.4.Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.5.Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066.6.Tokunboh I, Vales Montero M, Zopelaro Almeida MF, et al. Visual aids for patient, family, and physician decision making about endovascular thrombectomy for acute ischemic stroke. Stroke. 2018;49(1):90-97.7.Nelson W, Reyna VF, Fagerlin A, Lipkus I, Peters E. Clinical implications of numeracy: theory and practice. Ann Behav Med. 2008;35(3):261-274. The percentage of Medicare beneficiaries who received hospice before death increased 23%-48% between 2000-2014.1 What is the association between hospice length of stay (LOS) and end-of-life healthcare utilization and costs among hemodialysis (HD) patients? This cross-sectional observational study examined the association between end-of-life hospice LOS and healthcare utilization and costs among Medicare beneficiaries who had received maintenance HD. Patients in the US Renal Data System registry who died 2000-2014, and were enrolled in fee-for-service Parts A and B, were identified. The subset for whom the most recent pre-death treatment was HD (vs. kidney transplant or peritoneal dialysis) was analyzed. Primary outcomes included hospital admission, intensive care unit (ICU) admission, last-month-of-life intensive procedures, in-hospital death, and last-week-of-life Medicare costs. Generalized linear models were used. Beneficiaries (n=770,191) were mean (SD) age 75 (11) years, and 54% male. Twenty percent were receiving hospice services upon death, of whom 42% received hospice for ≤3 days. In adjusted analyses, vs. patients not receiving hospice, patients hospice-enrolled for ≤3 days were less likely to die in hospital (14% vs. 55%; P<.001) or to undergo a last-month-of-life intensive procedure (18% vs. 32%; P<.001) but had higher rates of hospitalization (84% vs. 74%; P<.001) and ICU admission (54% vs. 51%; P<.001) as well as similar last-week-of-life Medicare costs ($10,756 vs. $10,871; P=.08). Hospice LOS >3 days was associated with progressively lower utilization rates and costs, especially for those in hospice ≥15 days (35% were hospitalized and 17% were ICU-admitted in the last month of life, and last-week-of-life Medicare costs averaged $3,221). Unlike other diagnoses in which even brief hospice admissions are associated with reduced costs and lower ICU utilization at the end of life,2 this study demonstrates that short hospice LOS for end-stage renal disease (ESRD) frequently follow expensive, intensive hospitalizations. HD patients face unique barriers to hospice enrollment3: lack of availability of dialysis while enrolled and acute, unpredictable complications affecting prognostication. Evidence shows that HD may not benefit elderly people with multiple comorbidities.4 Clinicians should be encouraged to have early, frank discussions with ESRD patients about when to forgo HD if nonbeneficial, when continuation of HD is beneficial, and when discontinuation is appropriate. This approach allows earlier hospice transitions and hospital avoidance. This article does not address the growing number of patients managed conservatively without dialysis, an area of needed further research. Despite more hospice for ESRD patients, late referrals and aggressive prehospice care limit clinical and financial benefits for this key population. Nina O'Connor, MD FAAHPM, University of Pennsylvania Health System, Philadelphia, PA. Wachterman MW, Hailpern SM, Keating NL, Kurella Tamura M, O'Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med. 2018;178(6):792-799. 1.Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare payment policy. Retrieved from http://medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=0. Published March 2016. Accessed July 6, 2017.2.Kelley AS, Deb P, Du Q, Aldridge Carlson MD, Morrison RS. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff. 2013;32(3):552-561.3.Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 11, End Stage Renal Disease. Washington, DC: Centers for Medicare and Medicaid Services; 2016.4.Hussain JA, Mooney A, Russon L. Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease. Palliat Med. 2013;27(9): 829-839. Cultural competency, the “ongoing commitment or institutionalization of appropriate practices and policies for diverse populations,” can reduce healthcare disparities.1,2 What is the factor structure of the cultural competency items included in the agency component of the public-use National Home and Hospice Care Survey (NHHCS) file? This study examined the factor structure and internal consistency for the 9 cultural competency items in the 2007 NHHCS, available from the National Center for Health Statistics.3 The survey data were collected 2007-2008 using in-person interviews with agency directors and staff. Interviewees utilized administrative records and patient medical records to answer survey questions. Exploratory and confirmatory factor analyses were used. The survey sample included 1,545 home health, hospice, or mixed home health and hospice care (HHHC) agencies that were randomly selected, with probability proportional to size, from a sampling frame of >15,000 organizations. Exploratory factor analyses suggested an interpretable 2-factor solution with excellent model fit (root mean square error of approximation [RMSEA] 0.01, comparative fit index [CFI] 1.00, Tucker-Lewis Index [TLI] 0.99, and standard root mean square residual 0.02). The first factor comprised 3 items (questions about the mandatory cultural competency training provided to staff, providers, and volunteers), as did the second factor (questions about the use of interpreters, educational material in different languages, and multilingual staff). These 2 factors correlated at r=0.34. The remaining 3 items did not load well on these factors. A confirmatory factor analysis model without cross-loadings supported the 2-factor model: X2/8=9.50, P=0.30, RMSEA=0.01, CFI=0.99, and TLI=0.99. Findings from this study suggest that 6 items from the NHHCS survey can be used to assess two key aspects of cultural competence, mandatory training, and provision of cultural competence communication practices. Although the use of a nationally representative sample of HHHC agencies is a strength, hospice agencies were only 15% of the weighted sample, potentially limiting generalization of findings to hospice settings. Interestingly, compared to home health agencies, hospice and mixed agencies were less likely to provide mandatory training to staff and direct care providers and culturally competent communication. Study limitations include lack of assessment of predictive validity of the measures and of other important aspects of cultural competency, such as individual healthcare provider adherence to cultural competency practices. This brief, standardized measure may help stimulate research and quality improvement efforts in the important issue of cultural competence in HHHC agencies. Laura Porter, PhD, Duke University Medical Center, Durham, NC. AbuDagga A, Mara CA, Carle AC, Weech-Maldonado R. Factor structure of the cultural competence items in the National Home and Hospice Care Survey. Med Care. 2018;56(4):e21-e25. 1.Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(Suppl 1):181-217.2.Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):992-1000.3.National Center for Health Statistics. National Home and Hospice Care Survey, survey methodology, documentation, and data files. 2009. Retrieved from www.cdc.gov/nchs/nhhcs/nhhcs_questionnaires.htm. Accessed February 5, 2017. Limited evidence supports ketamine hydrochloride's use as an adjuvant treatment for cancer-related neuropathic pain (NP).1 How does oral ketamine perform in a placebo-controlled trial? This multicenter, double-blind trial in the United Kingdom tested oral ketamine for cancer-related NP. Patients had been treated with adjuvant analgesics for NP, ineffectively, and preexisting analgesia was continued throughout the trial. Patients were centrally randomized using minimization, then ketamine or placebo was titrated across 16 days (starting dosage=40 mg/d, maximum=400 mg/d). The primary end point was analgesic benefit duration (improvement of ≥5 points in the index pain score [Sensory Component of the Short Form McGill Pain Questionnaire]). Analysis (intention-to-treat) used Cox proportional hazards regression with a confirmatory log-rank test. Patients (n=214) were median age 58 years (IQR=51-66) and 66% female, with comparable between-arm demographics. A variety of cancer types were represented (75% in remission), and 98% of patients were following NP treatment regimens. The median morphine equivalent daily dose was 0 mg. There was no between-arm difference in analgesic benefit duration (ketamine to placebo hazard ratio=0.95; 95% CI=0.70-1.29; P=.75) supported by the log-rank test (P=.69).The median analgesic benefit duration was 0 days (95% CI=0-1) for ketamine and 0 days (95% CI=0-4) for placebo. Thirty-two percent receiving ketamine (vs. 36% placebo) maintained analgesic benefit at day 4 of the stable dosage (95% CI for difference, -17%-8%). Corresponding day 16 figures were 22% receiving ketamine (vs. 25% placebo; 95% CI for difference, -14%-9%). Serious adverse events included cognitive disturbance, dizziness, fatigue, nausea, and somnolence: 8 receiving ketamine (vs. 10 placebo). Ketamine has been used empirically in patients with cancer pain as a co-analgesic, but even well-designed trials have not provided conclusive evidence to support such use. This is the first randomized study to evaluate its role in the treatment of cancer-related neuropathic pain (most patients in the study had chemo-induced peripheral neuropathy and in remission from their malignancy). This report is limited. The authors measured pain improvement but did not mention the severity of pain at baseline. Eighty-six patients were excluded because of “treatment failure,” but the criteria for such a decision are not mentioned. The reason for the titration phase length differences between the intervention and placebo groups are unclear. In addition, no one in either of the groups was on opioids at the start of the trial. Surprisingly, despite ketamine dose titration, serious adverse events were not much different in the ketamine vs placebo groups. Ketamine does not seem to be effective in neuropathic cancer pain (specifically chemo-induced peripheral neuropathy). Giovanni Elia, MD FAAHPM, University of California San Francisco, San Francisco, CA. Fallon MT, Wilcock A, Kelly CA, et al. Oral ketamine vs placebo in patients with cancer-related neuropathic pain: a randomized clinical trial. JAMA Oncol. 2018;4(6):870-872. 1.Bell RF, Eccleston C, Kalso EA. Ketamine as an adjuvant to opioids for cancer pain. Cochrane Database Syst Rev. 2012;11:CD003351. Friedrichsdorf SJ. Contemporary pediatric palliative care: myths and barriers to integration into clinical care. Curr Pediatr Rev. 2017;13(1):8-12. https://www.ncbi.nlm.nih.gov/pubmed/27848889. Relatively few palliative care physicians are pediatricians, but most will be called upon to care for children at some point. This is a helpful overview of how to integrate palliative care into the care of children with life-limiting illness. Sourkes BM. Children's experience of symptoms: narratives through words and images. Children (Basel). 2018;5(4):pii:E53. https://www.ncbi.nlm.nih.gov/pubmed/29671836. Appreciating and measuring suffering in children can be difficult, and this overview of qualitative and visual descriptions of various forms of suffering is an invaluable overview. Blazin LJ, Cecchini C, Habashy C, Kaye EC, Baker JN. Communicating effectively in pediatric cancer care: translating evidence into practice. Children (Basel). 2018;5(3):pii:E40. https://www.ncbi.nlm.nih.gov/pubmed/29534479. Although certain core principles of communication translate well into pediatric palliative care, unique aspects of childhood require additional attention. This article reviews the current literature and provides practical guidance in communicating with children. Haines ER, Frost AC, Kane HL, Rokoske FS. Barriers to accessing palliative care for pediatric patients with cancer: a review of the literature. Cancer. 2018;124(11):2278-2288. https://www.ncbi.nlm.nih.gov/pubmed/29451689. Integrating palliative care into pediatric oncology can be challenging because of concerns that families “aren't ready” for palliative care or the presumption toward aggressive treatment is inconsistent with palliative care. This review identifies other common obstacles and recommends ways to overcome them. PC-FACS Feedback We appreciate your feedback. Help us help you—send your comments to [email protected] . PC-FACS was created in 2005 by Founding Editor-in-Chief Amy P. Abernethy, MD, PhD, FACP, FAAHPM. The Academy is deeply grateful to Dr. Abernethy for creating this important publication and for her many contributions to the field of hospice and palliative medicine. PC-FACS is edited by Editor-in-Chief, Mellar P. Davis, MD, FCCP, FAAHPM, of the Geisinger Health System, and Associate Editor-in-Chief, Robert M. Arnold, MD, FAAHPM, of the University of Pittsburgh Medical Center. All critical summaries are written by Jeff Fortin, MD. AAHPM thanks the following PC-FACS Editorial Board members for their review of the critical summaries and preparation of the commentaries: Editorial Leadership Mellar P. Davis, MD, FCCP, FAAHPM, Editor-in-Chief Robert M. Arnold, MD, FAAHPM, Associate Editor-in-Chief Basic Science Rony Dev, DO, MS, FACP, FAAHPM, Senior Section Editor Amy L. Davis, DO, MS, FACP, FAAHPM Rosene Pirrello, RPh Jacob Strand, MD Bioethics, Humanities, and Spirituality Jessica A. Moore, DHCE, MA, Senior Section Editor Timothy Mark Corbett, MD, MA, HMDC, FAAHPM Adam Marks, MD Beth Popp, MD, HMDC, FAAHPM, FACP Erin Zahradnik, MD Geriatrics and Care Transitions Eric Widera, MD, FAAHPM, Senior Section Editor Gouri Bhattacharyya, MD, MRCP David B. Brecher, MD, FAAFP, FAAHPM Elizabeth Chuang, MD, MPH Catherine Bree Johnston, MD, MPH Hospice, Hospice and Palliative Medicine Interface, and Regulatory Issues Joel S. Policzer, MD, FACP, FAAHPM, Senior Section Editor Christopher Jones, MD, FAAHPM Nina O'Connor, MD Renato Samala, MD, FACP Pediatrics Robert C. Macauley, MD, FAAP, FAAHPM, Senior Section Editor Christopher A. Collura, MD Sue Sreedhar Kevin Madden, MD Rachel Thienprayoon, MD Psychosocial Ronit Elk, PhD, Senior Section Editor Dan Handel, MD Laura Porter, PhD Karen Ogle, MD, FAAHPM Abby R. Rosenberg, MD, MS, FAAP Symptom Assessment and Management Marcin Chwistek, MD, FAAHPM, Senior Section Editor Dulce M. Cruz Oliver, MD, CMD, FAAHPM, AGSF Giovanni Elia, MD, FAAHPM Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE Jason A. Webb, MD Medical Writers Jeff M. Fortin, PhD (September 2016-present) Lana Christian, MS (August 2015-August 2016) Moses Sandrof (October 2014-July 2015) Jane Wheeler (July 2005-September 2014) AAHPM Staff Laura Davis, CAE, Director, Marketing and Membership Allison Lundberg, Manager, Marketing and Membership Andie Bernard, Managing Editor AAHPM Publications Committee (Joanne Wolfe, MD, chair) The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 8735 W. Higgins Road, Suite 300 Chicago, IL 60631, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: [email protected] Website: www.aahpm.org