Palliative Care Clinicians Research Articles

Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure

Evidence suggests system-level norms and care processes influence individual patients’ medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient’s critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients’ individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.

Navigating the Storm: Documenting the Experience of Inpatient Registered Nurses Amid the COVID Pandemic-Palliative Care Team Insights.

Nominal research illustrates the lived experience of intensive care unit registered nurses during the COVID pandemic. Palliative care team leaders and nurse researchers designed this cross-sectional study to discover opportunities for palliative care team members to enhance the experience of nurses who cared for critically ill patients during this challenging time. The study aimed to compare the effect of caring for patients in COVID versus non-COVID units. Surveys were distributed after the area's initial COVID patient influx. Questions included general demographics, the Professional Quality of Life survey instrument (measuring compassion satisfaction, burnout, and secondary traumatic stress), and open-ended questions to identify protective factors and unique challenges. Across 5 care settings with 311 nurses eligible for the study in total, 90 completed the survey. The population consisted of COVID-designated unit nurses (n = 48, 53.33%) and non-COVID unit nurses (n = 42, 46.67%). Analysis between COVID-designated and non-COVID units revealed significantly lower mean compassion scores and significantly higher burnout and stress scores among those working within COVID-designated units. Despite higher levels of burnout and stress and lower levels of compassion, nurses identified protective factors that improved coping and described challenges they encountered. Palliative care clinicians used insights to design interventions to mitigate identified challenges and stressors.

An Electronically Delivered Person-Centered Narrative Intervention for Persons Receiving Palliative Care: Protocol for a Mixed Methods Study

In the health care setting, electronic health records (EHRs) are one of the primary modes of communication about patients, but most of this information is clinician centered. There is a need to consider the patient as a person and integrate their perspectives into their health record. Incorporating a patient's narrative into the EHR provides an opportunity to communicate patients' cultural values and beliefs to the health care team and has the potential to improve patient-clinician communication. This paper describes the protocol to evaluate the integration of an adapted person-centered narrative intervention (PCNI). This adaptation builds on our previous research centered on the implementation of PCNIs. The adaptation for this study includes an all-electronic delivery of a PCNI in an outpatient clinical setting. This research protocol aims to evaluate the feasibility, usability, and effects of the all-electronic delivery of a PCNI in an outpatient setting on patient-reported outcomes. The first objective of this study is to identify the barriers and facilitators of an internet-based-delivered PCNI from the perspectives of persons living with serious illness and their clinicians. The second objective is to conduct acceptability, usability, and intervention fidelity testing to determine the essential requirements for the EHR integration of an internet-based-delivered PCNI. The third objective is to test the feasibility of the PCNI in an outpatient clinic setting. Using a mixed method design, this single-arm intervention feasibility study was delivered over approximately 3 to 4 weeks. Patient participant recruitment was conducted via screening outpatient palliative care clinic schedules weekly for upcoming new palliative care patient visits and then emailing potential patient participants to notify them about the study. The PCNI was delivered via email and Zoom app. Patient-reported outcome measures were completed by patient participants at baseline, 24 to 48 hours after PCNI, and after the initial palliative care clinic visit, approximately 1 month after baseline. Inclusion criteria included having the capacity to give consent and having an upcoming initial outpatient palliative care clinic visit. The recruitment of participants began in April 2021. A total of 189 potential patient participants were approached via email, and 20 patient participants were enrolled, with data having been collected from May 2021 to September 2022. A total of 7 clinician participants were enrolled, with a total of 3 clinician exit interviews and 1 focus group (n=5), which was conducted in October 2022. Data analysis is expected to be completed by the end of June 2023. The findings from this study, combined with those from other PCNI studies conducted in acute care settings, have the potential to influence clinical practices and policies and provide innovative avenues to integrate more person-centered care delivery. DERR1-10.2196/41787.

“My everyday life has returned to normal”- Experiences of patients and relatives with a palliative day care clinic: a qualitative evaluation study

PurposePalliative day care clinics (PDCCs) complement inpatient and home palliative care and provide access to a range of multi-professional services. However, they are not part of standard care in Germany. Yet, international studies show that PDCCs have a positive impact on e.g. quality of life.To evaluate one of the firstPDCCs in Germany (Aschaffenburg-Alzenau (PDCC-AA)) by describing theexperiences, satisfaction, challenges, wishes of patients and relatives andpossible alternatives to treatment in the PDCC.MethodsQualitative study using semi-structuredtelephone interviews. Data was analyzed using qualitative structuring contentanalysis according to Kuckartz with deductive a priori categories and inductivesubcategories.ResultsA total of 31 patients and 38 relativescompleted telephone interviews. The majority of patients were diagnosed with a canceror tumor disease. The following four main themes emerged: (1) alternatives totreatment at the PDCC, (2) symptom relief, (3) sense of security, (4) “everydaylife framing” (normality of everyday life).Participants valued the medicaltreatment (especially for pain), psychosocial support given and having directaccess to a range of services (e.g., wound care and pleural drainage), whilerelatives valued being provided respite services. A sense of security,availability of therapies, and devoted time that healthcare providers spent toexplain e.g., treatment options were mentioned most positively, as well asconfidence in dealing with the illness. As to whether there was an alternativeto treatment in the PDCC, some saw further inpatient stays, the emergency roomor care by general practitioners as options (although not preferred). Patientsexpressed concern that they were not treated and informed according to theirneeds in other care settings.ConclusionsPDCCs may close a gap betweeninpatient and home palliative care. Participants mentioned that hospital stayscan be delayed or even prevented.

Integrating Palliative Care into Oncology Care Worldwide: The Right Care in the Right Place at the Right Time.

While the benefits of early palliative care are indisputable, most of the current evidence has emerged from resource-rich settings in urban areas of high-income countries, with an emphasis on solid tumors in outpatient settings; this model of palliative care integration is not currently scalable internationally. A shortage of specialist palliative care clinicians means that in order to meet the needs of all patients who require support at any point along their advanced cancer trajectory, palliative care must also be provided by family physicians and oncology clinicians who require training and mentorship. Models of care that facilitate the timely provision of seamless palliative care across all settings (inpatient, outpatient, and home-based care), with clear communication between clinicians, are crucial to the provision of patient-centred palliative care. The unique needs of patients with hematological malignancies must be further explored and existing models of palliative care provision modified to meet these needs. Finally, care must be provided in an equitable and culturally sensitive manner, recognizing the challenges associated with the delivery of high-quality palliative care to both patients in high-income countries who live in rural areas, as well as to those in low- and middle-income countries. A one-size-fits-all model will not suffice, and there is an urgent need to develop innovative context-specific models of palliative care integration worldwide, in order to provide the right care, in the right place, and at the right time.

Pilot Study Evaluating Cross-Disciplinary Educational Material to Improve Patients' Knowledge of Palliative Radiation Therapy.

Palliative radiation therapy (PRT) is underutilized, partially due to misconceptions about its risks, benefits, and indications. The objective of this pilot study was to determine if patients with metastatic cancer would gain knowledge from educational material describing PRT and perceive it as useful in their care. A one-page handout conveying information about the purpose, logistics, benefits, risks, and common indications for PRT was offered to patients undergoing treatment for incurable, metastatic solid tumors in one palliative care clinic and four medical oncology clinics. Participants read the handout, then completed a questionnaire assessing its perceived value. Seventy patients participated between June and December 2021. Sixty-five patients (93%) felt they learned from the handout (40% learned "lots"), and 69 (99%) felt the information was useful (53% "very useful"). Twenty-one patients (30%) were previously unaware that PRT can relieve symptoms, 55 (79%) were unaware that PRT can be delivered in five treatments or less, and 43 (61%) were unaware that PRT usually has few side effects. Sixteen patients (23%) felt they currently had symptoms not being treated well enough, and 34 (49%) felt they had symptoms that radiation might help with. Afterwards, most patients felt more comfortable bringing symptoms to a medical oncologist's (n = 57, 78%) or radiation oncologist's (n = 51, 70%) attention. Patient-directed educational material about PRT, provided outside of a radiation oncology department, was perceived by patients as improving their knowledge and adding value in their care, independent of prior exposure to a radiation oncologist.

Routine patient assessment and the use of patient-reported outcomes in specialized palliative care in Japan

BackgroundDiscrepancies in symptom assessment between providers and patients are reported in cancer care, and the use of patient-reported outcome measures (PROMs) has been recommended for patients receiving palliative care. However, the status of the routine use of PROMs in palliative care in Japan is presently unclear. Therefore, this study aimed to clarify this complex question. To this end, we administered a questionnaire survey either online or via telephone interviews (questionnaire: sent to 427 designated cancer hospitals, 423 palliative care units [PCUs], and 197 home hospices; interviews: conducted at 13 designated cancer hospitals, nine PCUs, and two home hospices).ResultsQuestionnaires were returned from 458 institutions (44% response rate). We found that 35 palliative care teams (PCTs, 15%), 66 outpatient palliative care services (29%), 24 PCUs (11%) and one (5%) home hospice routinely used PROMs. The most frequently implemented instrument was the Comprehensive Care Needs Survey questionnaire. Moreover, 99 institutions (92%) that routinely used PROMs responded these instruments as useful in relieving patients’ symptoms; and moreover, the response rate in regard to usefulness in symptom management was higher than that of institutions that did not routinely use PROMs (p = 0.002); > 50% of the institutions that routinely used PROMs stated that use of these instruments was influenced by disease progression and patients’ cognitive function. Moreover, 24 institutions agreed to be interviewed, and interviews demonstrated the benefits of and the barriers to the implementation of PROMs. Effective methods used in the implementation of PROMs were introduced as efforts to reduce the burden placed on patients and to promote healthcare providers’ education in the use of PROMs.ConclusionsThis survey quantified the status of the routine use of PROMs within specialized palliative care in Japan, revealed barriers to wider PROM use, and identified needed innovations. Only 108 institutions (24%) routinely used PROMs within specialized palliative care. Based on the results of the study, it is necessary to carefully consider the usefulness of PROs in clinical palliative care, perform careful selection of PROMs according to the patient's condition, and evaluate how specifically to introduce and operate PROMs.

Together Is Better: A Combined Palliative Care and Psychiatry Substance Use Disorder Clinic for Patients with Advanced Cancer (TH109B)

Together Is Better: A Combined Palliative Care and Psychiatry Substance Use Disorder Clinic for Patients with Advanced Cancer (TH109B)

Telehealth outpatient palliative care in the COVID-19 pandemic: patient experience qualitative study

ObjectivesOutpatient in-person early palliative care improves quality of life for patients with advanced cancer. The COVID-19 pandemic forced a rapid shift to telehealth visits; however, little is known about how...

Top Ten Tips Palliative Care Clinicians Should Know About Working With Adults Receiving Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is an invasive intervention that is both resource- and labor-intensive. It can also be emotionally challenging for all involved. Palliative care (PC) clinicians can support adult patients, families, surrogate decision makers, and the interdisciplinary team (IDT) throughout ECMO, starting at the time of ECMO initiation through discontinuation and to bereavement in the event of a patient's death. In addition to knowing the basics of ECMO circuitry, indications to start ECMO, and the complex decision points throughout treatment, PC clinicians must understand the critical need for specialist and IDT coordination when discussing prognosis and resuscitation, clarifying goals of care, and identifying future treatment options. Not only are PC clinicians' skills needed to manage symptoms and psychosocial needs but also during end-of-life care, which can often be rapid and requires team consensus to ensure a smooth clinical process with continuous family support. While using their expert communication skills to conduct frequent family meetings, ideally starting within one week of ECMO initiation and weekly thereafter, PC clinicians offer a consistent presence and "big picture" perspective for patients and families, while other members of the IDT may rotate regularly. PC clinicians will also be called on to assist members of the IDT to debrief about the understandable moral and emotional distress they may experience while providing care for patients receiving ECMO and their families.

Feasibility of an embedded palliative care clinic model for patients with an advanced thoracic malignancy

PurposeEarly palliative care (PC) with standard oncology care has demonstrated improved patient outcomes, but multiple care delivery models are utilized. This study prospectively evaluated the feasibility of an embedded PC clinic model and collected patient-reported outcomes (PROs) and caregiver needs.MethodsIn this observational study of embedded outpatient PC for patients with advanced thoracic malignancies treated at The Ohio State University Thoracic Oncology clinic, patients received same-day coordinated oncology and palliative care visits at one clinic location. PC encounters included comprehensive symptom assessment and management, advanced care planning, and goals of care discussion. Multiple study assessments were utilized. We describe the feasibility of evaluating PROs and caregiver needs in an embedded PC model.ResultsForty patients and 28 caregivers were enrolled. PROs were collected at baseline and follow-up visits. Over a 12-month follow-up, 36 patients discontinued study participation due to hospice enrollment, death, study withdrawal, or COVID restrictions. At baseline, 32 patients (80%) rated distress as moderate-severe with clinically significant depression (44%) and anxiety (36%). Survey completion rates significantly decreased over time: 3 months (24 eligible, 66% completed), 6 months (17 eligible; 41% completed), 9 months (9 eligible; 44% completed), and 12 months (4 eligible; 50% completed).ConclusionWe found that an embedded PC clinic was feasible, although there were challenges encountered in longitudinal collection of PROs due to high study attrition. Ongoing assessment and expansion of this embedded PC model will continue to identify strengths and challenges to improve patient and caregiver outcomes.

Mitigating Moral Injury for Palliative Care Clinicians.

Palliative care clinicians (PCCs) in the United States face the combination of increasing burnout and a growing need for their services based on demographic changes and an increasing burden of serious illness. In addition to efforts to increase the number of PCCs and to train other clinicians in "primary palliative skills," we must address the burnout in the field to address the growing gap between need for this care and capacity to provide it. To address burnout in PCCs, we must develop solutions with the unique contributors to burnout in this field in mind. PCCs are particularly susceptible to moral distress and moral injury faced by all clinicians, and these states are inextricably linked to burnout. We propose three solutions to address moral distress and moral injury in PCCs to reduce burnout. These solutions are grounded in the dilemmas particular to palliative care and in best evidence: first, to create space for PCCs to confront moral challenges head-on; second, to integrate ethics consultations into care of some patients cared for by PCCs; and third, to reassess care models for PCCs. These approaches can mitigate burnout and thus address the growing gap in our ability to provide high-quality palliative care for those patients in need.

Letter to the Editor: Universal Screening for Substance Use Disorder in a Palliative Care Clinic: Results and Longitudinal Outcomes for Patients with Cancer

Journal of Palliative MedicineVol. 26, No. 2 Letters to the EditorLetter to the Editor: Universal Screening for Substance Use Disorder in a Palliative Care Clinic: Results and Longitudinal Outcomes for Patients with CancerMichael S. Dobson and Leslie J. BlackhallMichael S. DobsonAddress correspondence to: Michael S. Dobson, MD, Hospice of the Piedmont, 675 Peter Jefferson Parkway, Suite 300, Charlottesville, VA 22911-8618, USA E-mail Address: michael.dobson@hopva.orgHospice of the Piedmont, Charlottesville, Virginia, USA.Search for more papers by this author and Leslie J. BlackhallDivision of General Medicine, Geriatrics, and Palliative Care, Department of Internal Medicine, University of Virginia, Charlottesville, Virginia, USA.Search for more papers by this authorPublished Online:27 Jan 2023https://doi.org/10.1089/jpm.2022.0502AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Letter to the Editor: Universal Screening for Substance Use Disorder in a Palliative Care Clinic: Results and Longitudinal Outcomes for Patients with Cancer." Journal of Palliative Medicine, 26(2), pp. 160–161FiguresReferencesRelatedDetails Volume 26Issue 2Feb 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Michael S. Dobson and Leslie J. Blackhall.Letter to the Editor: Universal Screening for Substance Use Disorder in a Palliative Care Clinic: Results and Longitudinal Outcomes for Patients with Cancer.Journal of Palliative Medicine.Feb 2023.160-161.http://doi.org/10.1089/jpm.2022.0502Published in Volume: 26 Issue 2: January 27, 2023PDF download

Patient-Reported Quality Measures for Palliative Care: The Time is now.

While progress has been made in the ability to measure the quality of hospice and specialty palliative care, there are notable gaps. A recent analysis conducted by Center for Medicare and Medicaid Services (CMS) revealed a paucity of patient-reported measures, particularly in palliative care domains such as symptom management and communication. The research team, consisting of quality measure and survey developers, psychometricians, and palliative care clinicians, used established state-of-the art methods for developing and testing patient-reported measures. We applied a patient-centered, patient-engaged approach throughout the development and testing process. This sequential process included 1) an information gathering phase; 2) a pre-testing phase; 3) a testing phase; and 4) an endorsement phase. To fill quality measure gaps identified during the information gathering phase, we selected two draft measures ("Feeling Heard and Understood" and "Receiving Desired Help for Pain") for testing with patients receiving palliative care in clinic-based settings. In the pre-testing phase, we used an iterative process of cognitive interviews to refine draft items and corresponding response options for the proposed measures. The alpha pilot test supported establishment of protocols for the national beta field test. Measures met conventional criteria for reliability, had strong face and construct validity, and there was diversity in program level scores. The measures received National Quality Forum (NQF) endorsement. These measures highlight the key role of patient voices in palliative care and fill a much-needed gap for patient-reported experience measures in our field.

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review.

Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations. To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes. We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention. We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model. Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.

Should Outpatient Palliative Care Clinics in Cancer Centers be Stand Alone or Embedded?

Outpatient palliative care facilitates timely symptom management, psychosocial care and care planning. A growing number of cancer centers have either stand-alone or embedded outpatient palliative care clinics. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. One group advocates for stand-alone clinics, another for embedded, and the third group tries to find a balance. In the absence of evidence that directly compares the two models, factors such as cancer center size, palliative care team composition, clinic space availability, and financial considerations may drive the decision-making process at each institution. Stand-alone clinics may be more appropriate for larger academic cancer centers or palliative care programs with a more comprehensive interdisciplinary team, while embedded clinics may be more suited for smaller palliative care programs or community oncology programs to stimulate referrals. As outpatient clinic models continue to evolve, investigators need to document the referral and patient outcomes to inform practice.

Adapting an Advance Care Planning Intervention Delivered via Telehealth for Older Patients With Acute Myeloid Leukemia and Myelodysplastic Syndromes

Background Older patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) experience high-intensity care (eg, chemotherapy, hospitalization, and life-sustaining treatments) during the end of life. Early advance care planning (ACP) may promote end-of-life care that is more consistent with patients’ values and goals. As the COVID-19 pandemic has resulted in a rapid shift to telehealth, the use of such methods may improve access to ACP among this vulnerable population. Objective In this qualitative study, we aimed to adapt an evidence-based ACP intervention, the Serious Illness Care Program (SICP), to be delivered via telehealth for older adults with AML and MDS. Methods We conducted semistructured interviews with 14 oncology clinicians and 10 palliative care clinicians (physicians, advanced practitioners, and nurses), as well as 15 patients and 4 caregivers. Oncology and palliative care clinicians were recruited if they had cared for at least one patient with AML or MDS in the past year. Eligible patients were aged ≥60 years and had a diagnosis of AML or MDS, and their caregivers, if available, were recruited. Interviews were transcribed and qualitatively coded by 2 independent coders using MAXQDA (VERBI GmbH). We used directed content analyses focused on the content and delivery (telehealth vs in-person ACP) of the SICP. Results The mean ages of clinicians, patients, and caregivers were 48, 71, and 66 years, respectively. Health literacy, which was measured using the 6-item Cancer Health Literacy Test, was high in both patients (score: mean 6; range 0-6) and caregivers (score: mean 6). The majority of participants liked the intent and content of the SICP, with suggestions mainly on wording changes. One patient stated, “I wish I’d had a little of this back in the beginning, it would’ve eased my way through….” Oncologists expressed positive feedback for the SICP language “planting the seeds” of the ACP conversation, emphasizing that “it doesn’t mean that it’s going to happen.” Oncology and palliative care clinicians were comfortable with conducting ACP discussions via telehealth. Providers felt that the use of telehealth in ACP conversations would allow them to “deliver care with less burden.” Most patients and caregivers however were comfortable with conducting ACP conversations via telehealth “after the first couple of appointments [being] in-person” to first establish care. Lastly, providers felt that including a geriatric assessment summary prior to ACP conversations “helps to ground and anchor the discussion,” as it provides a “sense of baseline functionality…[and] quality of life.” Conclusions Overall, the SICP was well received by clinicians, patients, and caregivers. This stakeholder feedback will help us to better understand current barriers to ACP conversations and gauge whether telehealth may be utilized to help improve access to ACP. This feedback will be used to further refine the SICP intervention for a future single-arm pilot study. Trial Registration ClinicalTrials.gov NCT04745676; https://clinicaltrials.gov/ct2/show/NCT04745676 Acknowledgements Funding: R00CA237744, 5UG1CA189961, and R33AG059206. Conflicts of Interest None declared.

Development of Mobile Application-Based System for Improving Medication Adherence Among Cancer Patients Receiving Palliative Therapy.

Cancer patients seeking palliative care faces distressing symptoms which affect their quality of life adversely. Patients' lack of adherence to analgesics is one of the major factors contributing to the undertreatment of cancer pain. The objective of this paper is to outline the development of a mobile application-based system to develop a physician-patient relationship and to improve adherence to medications prescribed for cancer pain management. The mobile application-based system is developed using alarm and cloud based data sysncronisation for improving medication adherence and self-recording symptoms among cancer patients receiving palliative therapy at a palliative care clinic. Ten palliative medicine physicians tested the project website and the mobile application thoroughly instead of patients. The physician recoded the prescription and other details on the project website. The data transferred from website to mobile application. The mobile application reminded scheduled medication by alarm, collected medical adherence details, daily symptom observation, and their severity and SOS medication details. The data from the mobile application was transferred back to project website successfully. The developed system can directly improve the physician-patient relationship, and improve better communication and sharing of information between physician and patient. This will impact the quality of life of the patient, improve the awareness of the patient about the disease, and may reduce rate of hospitalisation. This will also help physicians to treat patients efficiently. The developed system is being tested under a randomised control trial study. The findings of the study can be generalised to all patients suffering from chronic illnesses and on long-term medications.

Opioid Disposal Practices of Patients With Life-Limiting Cancers in an Outpatient Palliative Care Clinic: A Cross-Sectional Study.

Background: Patients with life-limiting cancers are commonly prescribed opioids to manage pain, dyspnea, and cough. Proper prescription opioid disposal is essential to prevent poisonings and deaths. Objective: We examined opioid disposal practices of patients referred to a Canadian outpatient palliative care clinic (OPCC). The primary objective was to determine the prevalence of OPCC patients who did not routinely dispose their opioids. The secondary objectives were to examine their methods of opioid disposal and to identify patient characteristics associated with routine disposal of opioids. Design and Setting: This cross-sectional study involved a retrospective chart review of new, adult patients who were seen in a Canadian OPCC (September 2018-August 2019) and completed a survey about opioid-related constructs: source of prescriptions, use, storage, disposal, and knowledge about associated harms. Results: Among the 122 study participants, half (58/111, 52.3%) reported that they did not routinely dispose their opioids. The most common method of disposal was by giving them to pharmacists (69/88, 78.4%). Cannabis use (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.1-11.8) and neuropathic medication use (OR: 3.0, 95% CI: 1.2-7.2) were positively associated with routine disposal of opioids. Conversely, reports of an increased amount of opioid use in the past six months were negatively associated with routine disposal of opioids (OR: 0.38, 95% CI: 0.16-0.88). Conclusion: The high prevalence of people with life-limiting illnesses who do not routinely dispose their opioids requires increased attention. Interventions, such as education, are needed to reduce medication waste and opioid-related harms.

Time to FOCUS - 'Palliative Medicine Point-of-Care Ultrasound'.

Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.