Advanced Medical Illness Research Articles

Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments

Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments

Early integrated palliative care for haematology cancer patients-the impact on symptom burden in Hong Kong

Evidence showed that early palliative care could have many benefits in clinical outcomes for patients living with advanced medical illnesses. In fact, most of these studies have not involved patients with advanced haematologic cancer (HC), which are known to be associated with significant physical and psychological symptoms. In Hong Kong, an Early Integrated Palliative Care (EIPC) collaboration involving both Heamatology unit of Queen Mary Hospital (QMH) and the Palliative Medical Unit of Grantham Hospital (GH) has been started since early 2018 as a better way to improve the service gap. The HC patients failed 2 or more lines of cancer treatment are identified during the joint round and hematology clinic. Some of these patients will be referred to our PC services. Our joint PC clinic has multidisciplinary input from palliative care physicians, hematologists, and clinical psychologists. The clinic program is well coordinated and structured. The HC patients are initially seen by the parent team for disease treatment and then by GH PC team for symptom control and psychosocial care. This was a retrospective study with a review of the clinical charts and electronic healthcare records of all patients who attended the Hematology PC clinic from June 2018 to September 2020. For the inclusion criteria, patients were found eligible if they had prospectively completed Edmonton Symptom Assessment Scale (ESAS) assessments for at least the initial and follow-up visits within a range of ≥7 days and ≤60 days of the first visit. Thirty-eight patients ultimately agreed to the referral. The mean age was 70.5 (12.5) years old. Twenty-five patients (66%) had myelodysplastic syndrome (MDS); 10 (26%) had acute myeloid leukemia (AML). Around 50-60% of patients reported significant symptoms of fatigue, anxiety, drowsiness, and anorexia; 42% of patients had significantly depressed moods while 37% had pain. There were significant symptom improvements for pain, depression, and anxiety after follow-up visits. The study showed that our EIPC program resulted in a significant reduction in some of the important symptom item scores, including pain, anorexia, anxiety, and depression, after the follow-up visits.

Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments

For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit. To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care. This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage. Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers. Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure). A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02). In this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care. ClinicalTrials.gov Identifier: NCT04181294.

Impact of structured advance care planning program on patients' wish items and healthcare utilization.

Structured advance care planning (ACP) program is an important service in the end-of-life care for patients with advanced medical illness. We pioneered a structured and coordinated ACP program for patients with advanced malignancies and end-stage organ failure in Hong Kong. This study investigated the impact of a structured ACP program on the concordance rate for patients' final wishes, patient/family satisfaction, and the number of acute admissions (AA) and length of stay (LOS) in hospital. Patients with advanced malignancy or end-stage organ failure who were able to complete ACP forms during the current admission to medical units were recruited. Patients who could not complete ACP forms or <18 years of age were excluded. The ACP program comprised the following components: (I) baseline education (workshop/role play) in ACP sessions for linked nurses of different medical units; (II) structured ACP discussions with recruited patients and their proxies during admission, after any change in clinical status, and also at monthly intervals; (III) formal structured review of patients' goals at regular team meetings; (IV) "flagging" of advance directive (AD) in hospital computer system and (V) feedback to linked nurse on the congruence of care. Mentally competent patients who did not receive ACP and matched for disease and demographics were selected as controls in a 1:2.5 ratio. Two hundred forty-three patients were included for analysis between August 2016 and July 2017, of which 69 patients joined the ACP program and 174 of them did not. Two hundred and one patients (83%) had advanced cancer. All had done do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order in the ACP group. The concordance rates for patients' wishes on quality of life, end-of-life and funeral arrangements were 95%, 100% and 100% respectively. Over 70% of patients and their families (N=10) showed satisfaction with the program. The ACP group also had lower mean AA and shorter LOS (0.78±0.23 vs. 1.2±0.8 episode/patient, 4.6±1.7 vs. 7.5±2.5 days, P=0.037 and P=0.023 respectively) in the last 3 months of life compared with the non-ACP group. This ACP program achieved high concordance rate for patients' wish items and reduced healthcare utilization.

An Ethically Justified Approach That Integrates Advance Directives Discussions With Care of the Patient With Cancer.

Although the frequency of advance directives discussions may be increasing, there is a need to improve the quality of these discussions. In a range of advanced medical illnesses, including cancer, poor outcomes with advanced cardiopulmonary life support (ACLS) have been well documented. However, when speaking to patients at the end-of-life, physicians frequently withhold evidence-based information and guidance about prognosis or outcomes of ACLS. Tools and models developed to facilitate communication at the end-of-life do not explicitly include recommendations on advance directives and specifically do not discuss the available evidence on ACLS outcomes in the seriously ill. Here, we review the current literature on outcomes of ACLS and current tools and communications for end-of-life discussions. A majority of patients have a preference for truth-telling and guidance. We advocate an approach that integrates individual goals and preferences with a shared understanding of prognosis and appropriate management options, as judged and recommended by the disease experts, in order to reach an evidence-based decision on advance directives. This pragmatic and ethically justified approach emphasizes active empathic communication to prioritize the care of the patient over the mechanical details of ACLS, thereby aligning end-of-life discussions with current practices in other domains of medicine.

Integrating Palliative Care Social Workers into Subacute Settings: Feasibility of the Assessing & Listening to Individual Goals and Needs Intervention Trial.

Objectives: Determine feasibility, acceptability, and preliminary effects of the Palliative Care Social Worker-led ALIGN (Assessing & Listening to Individual Goals and Needs) intervention in older persons admitted to Skilled Nursing Facility (SNF) and their caregivers. Design: A pilot pragmatic randomized stepped wedge design of ALIGN versus usual care in three SNFs. Setting and Participants: One hundred and twenty older adults and caregivers (optional) with advanced medical illnesses. Measures: Primary outcomes were feasibility and acceptability. We collected exploratory patient-/caregiver-centered outcomes at baseline and three months and conducted a medical record review at six months to assess documentation of Advance Directives (AD). We also collected exploratory health care utilization data, including hospitalizations, mortality, and hospice utilization. Results: Of 179 patients approached, 120 enrolled (60 ALIGN patients with 15 caregivers and 60 usual care patients and 21 caregivers). Four intervention patients refused ALIGN visits, 8 patients died or discharged before initial visit, and 48 intervention patients received ALIGN visits, with ∼80% having caregivers participating in visits, regardless of caregiver study enrollment. Quantitative exploratory outcomes were not powered to detect a difference between groups. We found 91% of ALIGN patients had a completed AD in medical record compared to 39.6% of usual care patients (p < 0.001). Qualitative feedback from participants and SNF staff supported high acceptability and satisfaction with ALIGN. Conclusion and Clinical Implications: A pragmatic trial of the ALIGN intervention is feasible and preliminary effects suggest ALIGN is effective in increasing AD documentation. Further research is warranted to understand effects on caregivers and health care utilization. The current model for SNF does not address the palliative care needs of patients. ALIGN has potential to be an effective, scalable, acceptable, and reproducible intervention to improve certain palliative care outcomes within subacute settings.

Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses

The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED). This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport. Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport. We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.

Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study.

BackgroundInvasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care.ObjectiveThe aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality.MethodsThis study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.ResultsThe study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020.ConclusionsThe successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses.International Registered Report Identifier (IRRID)DERR1-10.2196/16301

Psychotherapy at the End of Life

Dr. Elisabeth Kübler-Ross is credited as one of the first clinicians to formalize recommendations for working with patients with advanced medical illnesses. In her seminal book, On Death and Dying, she identified a glaring gap in our understanding of how people cope with death, both on the part of the terminally ill patients that face death and as the clinicians who care for these patients. Now, 50 years later, a substantial and ever-growing body of research has identified “best practices” for end of life care and provides confirmation and support for many of the therapeutic practices originally recommended by Dr. Kübler-Ross. This paper reviews the empirical study of psychological well-being and distress at the end of life. Specifically, we review what has been learned from studies of patient desire for hastened death and the early debates around physician assisted suicide, as well as demonstrating how these studies, informed by existential principles, have led to the development of manualized psychotherapies for patients with advanced disease. The ultimate goal of these interventions has been to attenuate suffering and help terminally ill patients and their families maintain a sense of dignity, meaning, and peace as they approach the end of life. Two well-established, empirically supported psychotherapies for patients at the end of life, Dignity Therapy and Meaning Centered Psychotherapy are reviewed in detail.

Nonbeneficial Intensive Care: Misalignments Between Provider Assessments of Benefit and Use of Invasive Treatments.

The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians' impressions that ICU care may be nonbeneficial. Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit. There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians' impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score. Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

Integrating Palliative Care Social Workers into Sub-Acute Settings: Feasibility of the ALIGN Intervention Trial (S825)

1.Describe the justification for methodological approach in this pragmatic trial design.2.Discuss the justification for the ALIGN intervention and preliminary results of the intervention in the SNF setting. Sub-acute rehabilitation (SNF), intended for short stay care transitions, cares for 1/3 of older adults in the last six months of life with low penetration of hospice and palliative care. ALIGN (Assessing & Listening to Individual Goals and Needs) is a palliative care social worker led intervention aimed to improve quality of life (QOL), goals of care (GOC) alignment, and provide support to patients and caregivers. Determine the feasibility of conducting a trial of ALIGN in older persons and their caregivers admitted to SNF and conduct exploratory analysis of ALIGN vs usual care on patient goals of care alignment (curative, life-prolonging/rehabilitative, comfort), QOL (FACT-G), and caregiver reaction assessment (CRA) and burden (Zarit). To conduct a pilot pragmatic randomized step wedge design of the ALIGN intervention versus usual care in three SNFs with 120 older adults and caregivers (optional) admitted with advanced medical illness (LACE score >7) to determine feasibility and preliminary efficacy. To date, 362 SNF patients met illness criteria and the team was able to approach 127 patients within required 72 hours of admission. Enrollment rate for patients = 68%, caregivers = 36%. Caregivers are often not available to participate in-person, alternate approaches are being tested. Baseline GOC alignment = 50%. Baseline FACT-G = 70.0 (+16.9) demonstrating compromised QOL, CRA Self Esteem scale (1-5) = 1.8 (+0.5) showing some benefit finding, and Zarit = 14.5 (+9.2) showing moderate burden. A pragmatic trial of the ALIGN intervention is feasible and needed based on low GOC alignment, low QOL, and moderate caregiver burden.

Psychedelic-Assisted Therapies—Palliative Care Clinical & Research Priorities (TH317)

•Identify types of suffering of psychological, emotional, social, spiritual, or existential nature that are potential indications for supervised therapy involving psychedelic medications, as well as important contraindications to this class of drugs.•Critically evaluate published findings from the expanding evidence base of clinical research into psychedelic-assisted treatment of patients with depression, anxiety, demoralization, and existential and spiritual suffering. People with advanced medical illness often experience anxiety, feelings of hopelessness and loss of meaning and value of life. Some conclude that their life is not worth living and desire to hasten their deaths. Currently available treatments for depression, anxiety, and spiritual distress often fail to alleviate suffering among people who are seriously ill. Research involving psilocybin and related compounds have shown significant benefit suggesting that this class of drugs may offer therapeutic potential in treating persistent, non-physical suffering. During the 2018 AAHPM-HPNA Assembly Meeting a concurrent session on psychedelic therapy drew approximately 600 participants, indicating substantial interest among palliative care providers in the research, cautions, and potential clinical application of these medications. The 2019 session will build on this interest and the content of the previous session to begin defining priorities for research and clinical use of psychedelics within palliative care practice. Recent and ongoing clinical studies pertaining to psychedelic-assisted therapies in care of seriously ill patients will be reviewed. Session faculty will present results of key informant interviews conducted with palliative care clinicians and researchers regarding their priorities for future studies and therapeutic application of these medications. Survey items will include considerations of: a) patient selection and screening, b) frequency and duration of treatment sessions with specific drugs, c) selection of medications (entheogens and empathogens) in treating syndromes of depression, anxiety, demoralization and PTSD, d) necessary levels of supervision, e) safety and therapeutic influence of different settings. These results will inform discussion among session participants. A distillation of this interactive discussion will inform priorities for a developing Special Interest Group on Psychedelic Therapies.

Cognitive Improvement in Older Adults in the Year After Hip Fracture: Implications for Brain Resilience in Advanced Aging

We examined cognitive function in nondemented, nondelirious older adults 1 year post hip fracture. Prospective observational study. Three hundred eighty-six hip fracture patients aged 60 years and older with no history of cognitive impairment, such as clinical dementia or persistent delirium, recruited from eight area hospitals 2-3 days after hip surgery (week 0), and 101 older adults with no recent acute medical events for control comparison. Cognitive function was examined with the Repeatable Battery for the Assessment of Neuropsychological Status and the Short Blessed Test (SBT) at weeks 0 (SBT only), 4, and 52 using a repeated measures mixed model analysis. Baseline predictor variables included demographics, personality, genetic factors, and depressive symptom level. Hip fracture participants had lower cognitive scores than healthy comparisons. Cognitive scores improved in the hip fracture group relative to healthy comparison participants from week 4-52. The only significant predictor of cognitive improvement after hip fracture was education: individuals with college education showed cognitive improvement by week 52, while those with high school or less did not. Nondemented, nondelirious older adults suffering hip fracture have poorer cognitive function immediately after the fracture but then exhibit cognitive improvement over the ensuing year, especially among those with high education. This demonstrates brain resilience in older adults even in the context of advanced age, medical illness, and frailty.

Apoyo con Cariño (support with caring): RCT protocol to improve palliative care outcomes for Latinos with advanced medical illness.

Latinos are more likely to experience uncontrolled pain, and institutional death, and are less likely to engage in advance care planning. Efforts to increase access to palliative care must maximize primary palliative care and community based models to meet the ever-growing need in a culturally sensitive and congruent manner. Patient navigator interventions are community-based, culturally tailored models of care that have been successfully implemented to improve disease prevention, early diagnosis, and treatment. We have developed a patient navigation intervention to improve palliative care outcomes for seriously ill Latinos. We describe the protocol for a National Institute of Nursing Research-funded randomized controlled trial designed to determine the effectiveness of the manualized patient navigator intervention. We aim to enroll 240 Latino adults with non-cancer, advanced medical illness from both urban and rural clinical sites. Participants will be randomized to the intervention group (five palliative care patient navigator visits plus bilingual educational materials) or control group (usual care plus bilingual educational materials). Outcomes include quality of life (Functional Assessment of Chronic Illness Therapy), advance care planning (Advance Care Planning Engagement survey), pain (Brief Pain Inventory), symptom management (Edmonton Symptom Assessment Scale-revised), hospice utilization, and cost and utilization of healthcare resources. This culturally tailored, evidence-based, theory-driven, innovative patient navigation intervention has significant potential to improve palliative care for Latinos, and facilitate health equity in palliative and end-of-life care.

Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program

ContextIdentifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. ObjectivesThe objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. MethodsThis is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. ResultsNo significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268–$25,234). ConclusionThe Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.

Working With Decisionally Capable Patients Who Are Determined to End Their Own Lives.

Psychiatrists face complex, vexing, and often conflicting issues in assessing and managing patients with advanced medical illnesses who are determined to end their own lives. Substantial differences of opinion exist among psychiatrists regarding the roles they might take with such patients when the patients are decisionally capable and do not have clear-cut psychiatric disorders. Even those with psychiatric diagnoses often possess rational deliberative abilities and may make decisions to hasten death that are not impacted by their psychiatric disorder. How psychiatrists interact with these patients may be influenced by contradictory and even incompatible ethical, psychological, social, cultural, and professional biases. Tensions often exist between patients' autonomous preferences regarding their wish to die and psychiatrists' usual approaches to suicide prevention. To consider these issues, we review some ethical, legal, psychological, social, and clinical concerns; potential interventions; and support for psychiatrists caring for decisionally capable patients with advanced medical illness who wish to end their own lives. Although psychiatrists' work strongly focuses on suicide prevention, harms might result if suicide prevention becomes the only focus of treatment plans for these patients. We recast benefits and harms in such situations and make suggestions for assessing and managing such patients and for potentially offering assistance to families and other survivors. While psychiatrists should carefully think through each case on its own merits and seek consultation with experts, they should not act reflexively to prevent all deaths at any cost. We argue they may, in some cases, honor patients' and families' wishes and even collaborate with them around decisions to hasten death.

End-of-Life, Physician-Assisted Dying Challenge Traditional Medical Ethics

End-of-Life, Physician-Assisted Dying Challenge Traditional Medical Ethics

Palliative Care Symptom Management in The Emergency Department: The ABC's of Symptom Management for The Emergency Physician

BackgroundPalliative care is a rapidly evolving area of emergency medicine. With an estimated 5,000 to 10,000 baby boomers per day reaching retirement age, emergency departments (EDs) are treating more patients with chronic and serious disease. Palliative care offers comprehensive care for patients with advanced medical illness, aims to alleviate suffering and improve quality of life, and plays an important role in caring for these patients in the ED. ObjectivesWe sought to increase the emergency physician's knowledge of and comfort with symptom control in palliative and hospice patients. DiscussionHaving the skills to deliver efficient and appropriate palliative and hospice care is imperative for emergency physicians. Palliative care should be considered in any patient suffering from symptoms of a life-limiting illness, whereas hospice care should be considered in the patient with likely <6 months left to live. Palliative care is appropriate earlier in the course of disease, and is appropriate when the practitioner would not be surprised if the patient died in the next 2 years (“The Surprise Question”). This article discusses management in the ED of pain, nausea, dyspnea, agitation, and oral secretions in patients appropriate for hospice and palliative care. ConclusionThe need for palliative and hospice care in the ED is increasing, requiring that emergency physicians be familiar with palliative and hospice care and competent in the delivery of rapid symptom management in patients with severe and life-limiting disease.

End-of-life services for older people in residential care homes in Hong Kong.

Good end-of-life care is needed for older people living in residential care homes with advanced irreversible chronic medical illnesses and cancers. At present, the usual practice of residential care homes is to send older residents to acute care hospitals when they are unwell, and some residents will die in hospital. Dying in hospital without choice for older people may not be in alignment with the principle of 'good death'. There are many barriers for older people to die in the place of their choice, particularly in a residential care home. In the community, to enhance end-of-life care for elderly people living in residential care homes, pilot end-of-life programmes have been organised by community geriatric assessment teams. In 2015, the Hong Kong Hospital Authority started the 'Enhance community geriatric assessment team support to end-of-life patients in residential care homes for the elderly' programme in four clusters. In the hospital setting, an end-of-life clinical plan and end-of-life ward in geriatric step-down hospitals may improve the quality of death of elderly people. In September 2015, the Hospital Authority guideline on life-sustaining treatment for terminally ill people was updated. Among other key end-of-life issues, careful (comfort) hand feeding was first mentioned in the guideline. The possible establishment of enduring powers of attorney for health care decision-making and enhancement of careful (comfort) hand feeding are new developments in the coming years.

Utilization of palliative care services for cardiac arrest patients undergoing therapeutic hypothermia: A retrospective analysis

BackgroundPalliative care (PC) services are integral to the care of patients with advanced medical illnesses. Given the significant morbidity and mortality associated with cardiac arrest, we sought to measure the use and impact of PC in the care of patients treated with therapeutic hypothermia (TH). MethodsWe conducted a retrospective study of 317 consecutive patients undergoing TH after cardiac arrest. We compared intensive care unit (ICU) characteristics and clinical outcomes of subjects who received PC consultation (n=125) to those who did not (n=192). ResultsThe proportion of TH patients with PC consultations increased to greater than 60% by 2013, corresponding to our institution’s expansion of PC services, development of a dedicated PC unit, and integration of this service into our published TH protocol. In the TH population, time to return of spontaneous circulation (ROSC) was associated with higher inpatient mortality (p<0.001) and placement of a PC consult (p=0.011). TH patients who received PC consultation had longer ICU stays (p=0.034), more ventilator days (p<0.001), and higher inpatient mortality (p<0.001). When these measures were analyzed cohort-wide comparing all TH patients pre- and post-2013, at which time the frequency of PC consultation had dramatically increased, there were no statistically significant differences in ICU care or outcomes. ConclusionIn our population of cardiac arrest patients undergoing TH, the utilization of PC services has increased over time, particularly for those patients with high morbidity and mortality. Future randomized studies may further delineate optimal patient selection for PC consultation to better facilitate goals of care discussions and timely medical decision-making.