Specialty Palliative Care Research Articles

Community-Based Palliative Care: An APRN-Led Embedded Model for Advanced Lung Disease.

Community-based palliative care (CBPC) models address the growing needs of patients and caregivers with chronic and serious illnesses. From pediatrics to geriatrics, individuals prefer to receive care within their local community and at home. Delivering care at the community level and within the home improves health outcomes, reduces disparities, and supports local economic activity. Various models of CBPC have developed through partnerships with existing services, such as home health agencies, but ongoing challenges and barriers exist for further expansion of specialty palliative care. Advanced practice registered nurses increasingly manage chronic and serious illnesses and are essential for all health care teams, particularly for CBPC. As trusted providers within the community, advanced practice registered nurses create lasting relationships that allow for meaningful exchanges with patients and caregivers. This article reviewed the concept and features of CBPC offered within the United States and describes an advanced practice registered nurse-led embedded palliative care program for advanced lung disease.

“Life…Gets Turned Upside-Down…” Opportunities to Improve Palliative Care for High-Grade Glioma

ContextEarly palliative care referral is recommended broadly in oncology. Yet, few patients with high-grade gliomas (HGG) – highly aggressive brain tumors – receive specialty palliative care consultation. ObjectivesTo delineate unique needs of HGG patients relative to other oncology patients according to perceptions of a diverse sample of US palliative medicine physicians and neuro-oncologists in each of the eight domains of palliative care; and to describe contrasts between physician specialties on indications for and timing of specialty palliative care referrals in HGG. MethodsBetween September 2021 and May 2023, we conducted semi-structured, 40-minute interviews with ten palliative medicine physicians and ten neuro-oncologists. Participants were recruited via purposive sampling for diversity in geographic setting, years in practice, and practice structure. Interviews were audio-recorded, professionally transcribed, and coded by two investigators. Data were analyzed thematically using a qualitative, phenomenological approach. ResultsThe palliative care needs of HGG relative to other cancers across palliative care domains are distinguished by poor prognosis, physical and cognitive deficits, and neuropsychiatric symptoms. Themes on indications for palliative care referral differed between neuro-oncologists and palliative physicians. Neuro-oncologists favored selective referral for clinical indications such as high non-neurologic symptom burden requiring time-intensive management. Palliative physicians favored early referral of most HGG patients, to allow for maximal benefit across HGG trajectory. ConclusionPatients with HGG have unique palliative care needs that affect palliative care delivery across care domains. Bidirectional education, enhanced collaboration, and consensus guidelines may help overcome barriers to specialty palliative care referral.

Performance of an artificial intelligence/machine learning model designed to identify hospitalized patients with cancer who could benefit from timely specialized palliative care delivery.

1559 Background: Timely access to specialty Palliative Care (SPC) services provides significant benefits to hospitalized patients with cancer, including improvements in quality of life. However, many patients with cancer who could benefit from SPC suffer from lack of timely referral or do not receive SPC services. A previously published trial of an artificial intelligence/machine learning (AI/ML) model to predict need for SPC at Mayo Clinic increased timely SPC consultation of hospitalized patients overall. We sought to review the performance of this algorithm in patients with cancer across an expanded hospitalized population. Methods: The study population consisted of all patients admitted into a Mayo Clinic hospital in Minnesota, Wisconsin, Arizona and Florida between January 2020 and September 2023. Due to the size of the cohort a case-control sample of three controls for every case was created. Patients were considered to be a patient with cancer if they had at least one billing diagnosis up to 1 year prior to their index hospitalization from any of the 5 HCC categories denoting cancer: Metastatic Cancer and Acute Leukemia (HCC 8); Lung and Other Severe Cancers (HCC 9); Lymphoma and Other Cancers (HCC 10); Colorectal, Bladder, and Other Cancers (HCC 11); and Breast, Prostate, and Other Cancers and Tumors (HCC 12). The training data set consisted of 107,076 patient encounters with a total of 8,355,090 time periods of constant risk. An AI/ML model using gradient boosting methods which contained 269 variables (both static and time-varying) of various classes with SPC consultation treated as a time-to-event outcome was trained. Results: Due to the longitudinal nature of the prediction, performance was assessed using the max score AUC (using the max score a patient received during a given encounter prior to an event or discharge) to produce the AUC. The model had an overall AUC of 0.932 (0.929, 0.935 – 95% CI). We saw a decrease in performance of the AI/ML model in the Oncology population with an overall performance of 0.818 (0.806, 0.83). Some of the most influential variables were previous SPC visit, age, metastatic disease, acute leukemia diagnosis, and pain scores. Conclusions: An AI/ML model can effectively predict the need for an inpatient PC consult in a population of hospitalized patients with cancer. [Table: see text]

Patient Experiences of Specialty Palliative Care in the Perioperative Period for Cancer Surgery

ContextThough patients undergoing treatment for upper gastrointestinal (GI) cancers frequently experience a range of sequelae and disease recurrence, patients often do not receive specialty palliative care soon after diagnosis and it is unknown in what ways they may benefit. ObjectivesTo understand patient experiences of specialty palliative care in the perioperative period for patients seeking curative intent upper GI oncologic surgery. MethodsAs part of a randomized controlled trial, we conducted in-depth interviews between November 2019 and July 2021 with 23 patients in the intervention arm who were undergoing curative intent treatment for upper GI cancers and who were also followed by the specialty palliative care team. ResultsWe found five themes that characterized patient experiences and perceptions of specialty palliative care. Patients typically had limited prior awareness of palliative care (theme 1), but during the study, came to understand it as a “talking” intervention (theme 2). Patients whose concerns aligned with palliative care described it as being impactful on their care (theme 3). However, most patients expressed a focus on cure from their cancer and less perceived relevance for integration of palliative care (theme 4). Integrating specialist palliative care practitioners with surgical teams made it difficult for some patients to identify how palliative care practitioners differed from other members of their care team (theme 5). ConclusionWhile receipt of specialty palliative care in the perioperative period was generally perceived positively and patients appreciated palliative care visits, they did not describe many needs typically met by palliative care practitioners. Trial Registrationclinicaltrials.gov registration: NCT03611309.

Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers.

Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.

Oncologic outpatient specialty palliative care referral utilization: A single institution quality improvement project.

e23205 Background: ASCO recommends that late-stage and/or recurrent disease patients with a prognosis of 6-24 months receive specialty palliative care within eight weeks of diagnosis. Prior studies suggest only 30% of eligible patients are referred to outpatient palliative care. Little is known about existing referral patterns to direct quality improvement initiatives. Our aim was to characterize outpatient palliative care referral sources, timeliness, and completion rates across our cancer center. More broadly, this investigation may serve as a model for outpatient palliative care utilization improvement at other cancer centers. Methods: A single institution retrospective quality improvement study was conducted of patients in the seven oncology subspecialties with the most palliative care referrals from 2019 – 2022. Data collected included demographics, referral source, and utilization metrics. Outcomes were rate of referral completion and time from referral to first palliative care visit, hospice enrollment, and/or death. Descriptive statistics were performed. Results: 1671 outpatient specialty palliative care referrals were placed. 57% were initiated by medical oncologists, 21% by inpatient palliative care consulting service at hospital discharge, and 14% by surgical oncology. 27% of referred patients did not schedule an appointment. Gynecologic and breast cancer patients had the highest rates of being scheduled. Median time from referral to appointment was 20 days (interquartile range 9 – 30 days). Reasons patients did not utilize palliative care included transition to hospice (41%), lack of interest (41%), or death prior to visit (7%). 79% of patients seen by palliative care who died were enrolled in hospice. Median time from palliative care referral to hospice enrollment was 66 days (IQR 22 – 164 days), and median time from hospice enrollment to death was 13 days (IQR 5 – 31 days). Conclusions: In a single institution self-evaluation, most patients referred to outpatient specialty palliative care completed referral within thirty days. Within the context of this institution, relevant goals for quality improvement interventions include increasing palliative care referrals among surgical oncologists and shifting palliative care referrals earlier in the disease course and prior to need for inpatient hospital admission. Understanding the elements of the creation of our palliative care referral database and relevant data tracking may serve as a method for other institutions to target interventions that may improve uptake of outpatient palliative care referrals at cancer centers more broadly.

Rural palliative care in cancer: Using telemedicine to bridge the gap.

e13807 Background: Despite the rapid growth in palliative care (PC) services, many rural regions remain without access to specialty palliative care. Community-based telemedicine may offer solutions to underserved populations from rural areas within the United States. Methods: This is a retrospective review of the creation of 2 separate rural clinics attached to the VCU Massey Comprehensive Cancer Center at CMH in South Hill, VA in 2018 (with interruption related to the Covid-19 pandemic) and in Tappahannock, VA in 2021. In addition to operational descriptions a chart review was conducted of all encounters for these clinics. Care provided was coordinated by the University PC service and the oncology clinics, including nurses and oncologists. Regulatory, legal, Information Technology (IT), and systems logistics were developed in partnership for 6-9 months prior to each pilot. There were over 100 encounters from the two periods of care for CMH (2018 until paused for pandemic towards the end of 2020; and March of 2021 to current) and greater than 50 at Tappahannock. All visits were conducted in the rural oncology clinics with assistance of oncology nursing during the encounter. Results: The average patient age was 57, and over 90% had solid tumors. On average, patients had 1-2 telemedicine visits. The most common reason for referral was symptom management, predominantly pain. Edmonton Symptom Assessment scales were collected at all visits by oncology nursing. Physical exams were completed with electronic stethoscopes and supported by oncology nursing. Medications were prescribed to rural pharmacies electronically directly by the PC physician; for the periods of clinic over the course of the Covid-19 public health emergency this included prescriptions for controlled substances (almost exclusively long and short acting opioids). For patients requiring advance care planning documents were completed electronically or by trained interdisciplinary team members in clinic in partnership with the PC physician. Technological issues occurred rarely (less than 1% of visits) and resolved without IT involvement. Conclusions: Our pilot program integrated specialist palliative care into two rural oncology clinics providing supportive care, including symptom management and goals of care discussions. Further research should define optimal integration of PC telemedicine into rural oncology.

A Digital Therapeutic Application (ePAL) to Manage Pain in Patients With Advanced Cancer: A Randomized Controlled Trial

BackgroundPatients with advanced cancer often experience immense cancer pain that negatively impacts their quality of life. Interventions to address cancer-related pain are limited. MethodsWe conducted a randomized trial of a digital therapeutic app (ePAL) for patients with advanced cancer receiving care in a specialty palliative care clinic at a tertiary care hospital. Patients were randomized to ePAL or usual care. ePAL included 1) active pain monitoring; 2) artificial intelligence algorithm to triage patient symptoms; and 3) patient education to address barriers to pain management. Participants were instructed to use ePAL over eight weeks. Patient-reported pain symptoms were assessed at baseline, Week-4, and Week-8 (primary endpoint) using the Brief Pain Inventory. Secondary outcomes include pain-related hospitalizations by Week-8. ResultsWe enrolled 112 patients who were randomly assigned to ePAL (N = 56) or usual care (N = 56). Patients utilized ePAL on average 2.1 times per week to report pain symptoms, and 47.6% reported their pain at least once per week over eight weeks. Patients randomized to ePAL reported lower pain scores at Week-4 (mean: 3.16 vs. 4.28, P = 0.010) and week-8 (mean:2.99 vs. 4.05, P = 0.017), compared to those receiving usual care. Participants randomized to ePAL were less likely to experience a pain-related hospitalization compared to those in the usual care group (7.1% vs. 23.2% P = 0.018) ConclusionsePAL was associated with lower patient-reported pain and fewer pain-related hospitalizations compared to usual care in patients with advanced cancer. This study demonstrates the promise of digital therapeutics for improving patients’ symptoms while reducing burdensome hospitalizations.

A longitudinal, palliative care educational pilot in hematology-oncology fellowship training.

9007 Background: Despite national guidelines advocating that patients (pts) with advanced cancer receive dedicated palliative care (PC) services, many pts lack access to specialty PC, due to PC workforce shortage. Training hematology-oncologists (HOs) to provide primary PC could close this gap and ensure basic PC needs of pts are met. While HO fellowships require demonstration of competence in PC skills, studies have shown major deficits in PC knowledge, educational experiences and confidence. We designed a longitudinal, integrated, PC continuity rotation for HO fellows. We report feasibility, acceptability, perceived value, and impact on knowledge and practice of this novel educational model. Methods: Over 6 months, HO fellows identified patients with PC needs from their HO continuity practice and referred them to PC clinic. Fellows then saw those pts in PC clinic with the PC attending and in HO clinic with the HO attending, as well as during hospitalizations. Pt visits and HO fellow participation were tracked for feasibility. Fellows were surveyed before and after the rotation on skill confidence and knowledge, which were compared using generalized linear models for unmatched data. After the rotation, they were surveyed on acceptability and teaching quality; they also participated in a semi-structured interview assessing educational value. Fellows electronically gave informed consent for participation; the project was approved by the institutional IRB. Results: From 2018-2023, 19 fellows from 3 HO fellowship classes participated. All 19 referred 2-4 of their continuity oncology pts to the PC team and then followed these pts in both clinics longitudinally over 6 months. A total of 51 pts (#fellows-#pts: 9-2 pts; 7-3 pts; 3-4 pts) had a total of 132 PC visits. Fellows participated in 125/132 PC visits (95%); the majority were outpatient (94/132; 71%). From pre to post intervention, there was an improvement in fellows’ PC knowledge (mean 6.44/10 to 7.92, p<0.01) and overall feeling of preparedness to provide PC (mean 6.33/10 to 7.75, p<0.01). Ratings of skill confidence improved in 14 of 26 items (p<0.05), including titration of opioids, managing pain in pts with substance use disorder, recognizing when to consider methadone, and working with an interdisciplinary team. Of 17 fellows rating acceptability, 16 (94%) rated the rotation as valuable or extremely valuable, 15 (88%) agreed or strongly agreed the rotation structure was effective, and 17 (100%) agreed or strongly agreed the rotation both changed their clinical practice and helped them feel more engaged in working with their sickest pts. Conclusions: Our pilot study of a novel, longitudinal, integrated, PC continuity rotation for HO fellows was highly feasible and acceptable. The rotation changed clinical practice and improved fellows’ PC knowledge and skill confidence. This could serve as a model for integrating PC education into HO fellowships nationally.

Designing a Mentorship Program for APRNs in Specialty Palliative Care Practice.

As advanced practice registered nurses (APRNs) enter practice, support is crucial for success. Formal mentorship has been shown to improve employee turnover, job satisfaction, and clinical competence. In the wake of the COVID-19 pandemic, an APRN team specializing in palliative care experienced an unprecedented rate of staff turnover. As a result, the team decided to create a formal mentorship program to support newly hired colleagues and assist their transition to practice. A subcommittee of APRNs within the palliative care practice met to establish a mentorship practice framework, expectations for the program, and a methodology for matching mentors and mentees. The mentorship program was implemented with two cohorts comprising a total of five mentors and six mentees. It was evaluated by participants using surveys asking open-ended, qualitative questions. Both mentors and mentees reported finding the program valuable. Mentees felt the program helped their transition to practice, created a forum for peer support, and improved their clinical competence. Mentors said the program furthered their own professional development, advanced their clinical growth, and fostered a connection to colleagues. Employee engagement and alignment improved, and staff turnover decreased. Further work is needed to improve on the program framework and analyze the outcomes of mentorship.

How is Telehealth Used to Increase Access to Specialty Palliative Care? A Systematic Review

How is Telehealth Used to Increase Access to Specialty Palliative Care? A Systematic Review

Palliative care for patients with gastroesophageal cancer at all stages: a narrative review.

Gastroesophageal junction (GEJ) cancer is a highly morbid disease with a poor prognosis. While uncommon in the United States, globally it is ranked as the sixth or seventh most common cancer depending on survey tool. GEJ cancer presents a unique and challenging symptom profile for patients at all disease stages, regardless of histology. Even patients with early stage disease experience debilitating cancer-related symptoms and treatment side effects. The heavy symptom burden associated with this disease includes dysphagia, nausea and vomiting, pain, anxiety, depression and malnutrition. These symptoms require a multidisciplinary approach involving local therapies including radiation and stent placement, systemic cancer-directed therapy, nutritional support, and supportive medical management. This review aims to examine the unique symptom burden experienced by patients with GEJ cancer and provide an updated overview of symptom management techniques. A PubMed search was conducted using the terms "gastroesophageal junction cancer AND palliative care". Articles published from 2008 to 2022 with a primary focus on supportive care for patients with GEJ cancers were reviewed. A total of 119 articles were identified and screened in our database search. Of these, 22 full text articles met inclusion criteria and were reviewed. Seventeen articles addressed technical interventions for the alleviation of dysphagia, 1 article focused on nutrition, 1 article described the impact of multidisciplinary tumor boards, 1 article presented the effect of home nurse visits, 1 article described the use of antiemetics, and 1 article was a narrative review of supportive care. In this narrative review, we examine specific supportive care needs in the GEJ cancer population. While the predominant symptom addressed in the literature is dysphagia, patients with GEJ cancer carry a complex symptom burden from diagnosis, through cancer-directed therapy to end-of-life care. Early referral to specialty palliative care should be considered for all patients with GEJ cancer to foster symptom management and delivery of goal concordant care.

Primary and specialty palliative care utilization at a regional Burn center.

There is little research informing appropriate specialty palliative care consultation over primary palliative care practice, or the ability of the burn surgeon to perform skills such as effective goals of care discussions. We sought to characterize patterns of palliative care utilization and hypothesized that greater modified Baux (mBaux) and systemic organ failure assessment (SOFA) scores would correlate with increased specialty palliative involvement but have no relationship with primary palliative involvement. A retrospective chart review was conducted at a regional burn center between 2020-2021 including patients admitted with burns or inhalation injury and a mBaux score over 60, detailing circumstances of palliative consultation and goals of care discussions. 163 patients met criteria. Odds of specialty palliative consultation increased by 3.9% for each additional mBaux score point and 23.3% for every SOFA score point. The odds of a goals of care discussion by a burn surgeon increased by 3.5% for each mBaux score point and 23.9% for each SOFA score point. Those receiving palliative consultation tended to have greater burn surface area, graft complications, code status changes, and more goals of care discussions by any provider at admission; there was no difference in symptom control or hospital length of stay. Higher mBaux and SOFA scores correlate with increased odds of both specialty and primary palliative involvement in our cohort. There is bias in diverting both primary and specialty palliative care resources toward acutely ill patients and those with less immediate projected mortality may need additional attention.

Hopes, expectations, and informational needs in patients undergoing advanced heart failure therapy evaluations

BackgroundPatients undergoing evaluation for advanced heart failure therapies (AHT) are at a critical juncture of their illness. Guidelines recommend shared decision-making with patients and caregivers; however, the approach and content of these discussions is unknown. MethodsPatients referred to a specialty palliative care service during AHT evaluation between October 2018 and September 2022 were identified from electronic healthcare records. Goals of care conversations documented in an advance care planning module were analyzed for participants, content, and timing prior to transplant selection committee meeting. Primary outcomes included prevalence of documented hopes, worries, shared prognostic communication, illness understanding, treatment expectations, and information preferences. Patients were followed for a minimum of six months to evaluate secondary processes and clinical outcomes. Results94 patients (mean age 52.8 years, 76.6% male) met criteria. Most (97.9%, n=92) had illness understanding documented. In initial discussions, 76.3% (n=71) hoped to “live longer” and 67.7% (n=63) to “be independent”; thematic analysis supported these hopes with 91.0% of patients expecting “better functionality”. Most patients preferred multi-modal information and communication. During follow-up, 27.7% (n=26) had treatment decisions deferred at initial committee presentation, and 43.6% (n=41) were reviewed at multiple selection committee meetings. By the end of the study period, 53.2% (n=50) underwent one or more AHT and 24.5% (n=23) had died. ConclusionPatients undergoing the AHT evaluation process face considerable uncertainty. A standardized approach by a specialty palliative care service elicits patients’ illness understanding, hopes, worries, treatment expectations, and information preferences to promote shared decision-making at this critical time.

Trajectories of Health Care Contact Days for Patients With Stage IV Non–Small Cell Lung Cancer

Patients with stage IV non-small cell lung cancer (NSCLC) experience substantial morbidity and mortality. Contact days (ie, the number of days with health care contact outside the home) measure how much of a person's life is consumed by health care, yet little is known about patterns of contact days for patients with NSCLC. To describe the trajectories of contact days in patients with stage IV NSCLC and how trajectories vary by receipt of cancer-directed treatment in routine practice. A retrospective, population-based decedent cohort study was conducted in Ontario, Canada. Participants included adults aged 20 years or older who were diagnosed with stage IV NSCLC (January 1, 2014, to December 31, 2017) and died (January 1, 2014, to December 31, 2019); there was a maximum 2-year follow-up. Data analysis was conducted from February 22 to August 16, 2023. Systemic cancer-directed therapy (yes or no) and type of therapy (chemotherapy vs immunotherapy vs targeted therapy). Contact days (days with health care contact, outpatient or institution-based, outside the home) were identified through administrative data. The weekly percentage of contact days and fitted models with cubic splines were quantified to describe trajectories from diagnosis until death. A total of 5785 decedents with stage IV NSCLC were included (median age, 70 [IQR 62-77] years; 3108 [53.7%] were male, and 1985 [34.3%] received systemic therapy). The median overall survival was 108 (IQR, 49-426) days, median contact days were 36 (IQR, 21-62), and the median percentage that were contact days was 33.3%. A median of 5 (IQR, 2-10) days were spent with specialty palliative care. Patients who did not receive systemic therapy had a median overall survival of 66 (IQR, 34-130) days and median contact days of 28 (IQR, 17-44), of which a median of 5 (IQR, 2-9) days were spent with specialty palliative care. Overall and for subgroups, normalized trajectories followed a U-shaped distribution: contact days were most frequent immediately after diagnosis and before death. Patients who received targeted therapy had the lowest contact day rate during the trough (10.6%; vs immunotherapy, 15.4%; vs chemotherapy, 17.7%). In this cohort study, decedents with stage IV NSCLC had a median survival in the order of 3.5 months and spent 1 in every 3 days alive interacting with the health care system outside the home. These results highlight the need to better support patients and care partners, benchmark appropriateness, and improve care delivery.

Psychosocial Distress Screening Among Interprofessional Palliative Care Teams: A Narrative Review

With increased need for palliative care and limited staffing resources, non-social workers are increasingly responsible for screening for urgent psychosocial distress. The National Consensus Project guidelines call for all palliative care team members to be competent in screening across domains. Yet, in contrast to an abundance of evidence-informed tools for palliative social work assessments, standardization for interprofessional psychosocial screening is lacking. This lack of standardized practice may lead to harmful disparities in care delivery. The purpose of this narrative review is to examine current literature on evidence-informed practices for psychosocial screening within palliative care. Google Scholar, a university Summon library search engine, and prominent palliative care journals were searched using the same phrases to locate articles for inclusion. Each article was reviewed and synthesized across common themes. Although an abundance of validated screening tools exists for outpatient oncology-specific settings, there is minimal guidance on psychosocial screening tools intended for specialty palliative care. The most oft-cited tools have been met with concern for validity across diverse palliative care populations and settings. Additional research is needed to operationalize and measure brief psychosocial screening tools that can be validated for use by interprofessional palliative care teams, a stepping-stone for increased equity in palliative care practice.

Primary palliative care in the ICU.

Despite the best efforts of modern health care and critical care providers, many patients in the intensive care unit (ICU) will still die each year. The need for palliative care services in the ICU is common. Although specialty palliative care services provide excellent care and are a tremendous resource, every critical care provider should be able to provide the basics of palliative care themselves through the model of primary palliative care. Although it may be uncomfortable for the critical care provider at first, providing palliative care to our ICU patients can be a very rewarding experience. In this article, I discuss best practices for handling difficult conversations with patients and their families, helping patients and families make difficult decisions regarding the goals of care, and managing symptoms at the end of life.

Clinician perspectives on integrating neuro-oncology and palliative care for patients with high-grade glioma.

Patients with high-grade glioma have high palliative care needs, yet few receive palliative care consultation. This study aims to explore themes on (1) benefits of primary (delivered by neuro-oncologists) and specialty palliative care (SPC) and (2) barriers to SPC referral, according to a diverse sample of clinicians. From September 2021 to May 2023, 10 palliative physicians and 10 neuro-oncologists were recruited via purposive sampling for diversity in geographic setting, seniority, and practice structure. Semistructured, 45-minute interviews were audio-recorded, professionally transcribed, and coded by 2 investigators. A qualitative, phenomenological approach to thematic analysis was used. Regarding primary palliative care, (1) neuro-oncologists have primary ownership of cancer-directed treatment and palliative management and (2) the neuro-oncology clinic is glioma patients' medical home. Regarding SPC, (1) palliative specialists' approach is beneficial even without disease-specific expertise; (2) palliative specialists have time to comprehensively address palliative needs; and (3) earlier SPC enhances its benefits. For referral barriers, (1) appointment burden can be mitigated with telehealth, home-based, and embedded palliative care; (2) heightened stigma associating SPC with hospice in a population with high death anxiety can be mitigated with earlier referral to promote rapport-building; and (3) lack of neuro-oncologic expertise among palliative specialists can be mitigated by emphasizing their role in managing nonneurologic symptoms, coping support, and anticipatory guidance. These themes emphasize the central role of neuro-oncologists in addressing palliative care needs in glioma, without obviating the need for or benefits of SPC. Tailored models may be needed to optimize the balance of primary and specialty palliative care in glioma.

The Role and Professional Standards of the Adult-Gerontology Nurse Practitioner in Hospice and Palliative Care.

The adult/gerontology (gero) nurse practitioner (NP) delivers primary and/or specialty palliative care to persons and their families who live each day with a myriad of serious illnesses. In this role, the adult/gero NP uses their skill set to address the whole person (physical, psychological, social, and spiritual/existential) to improve the quality of life for persons they care for. This article is the fourth in a series of 6 highlighting the different roles of the adult/gero NP and the advanced certified hospice and palliative registered nurse, and how these 2 roles overlap. The purpose of this article was to provide details of education and certification pathways for these NP roles, describe the overlaps in clinical care, and illustrate how the adult/gero NP in palliative and hospice care can contribute to leadership in program development for care of persons and their families who live with serious illness.

Association Between Intensity and Timing of Specialty Palliative Care and Hospice Exposure With Quality of End-of-Life Care.

Background: Gaps remain in our understanding of the intensity and timing of specialty palliative care (SPC) exposure on end-of-life (EOL) outcomes. Objective: Examine the association between intensity and timing of SPC and hospice (HO) exposure on EOL care outcomes. Design, Settings, Participants: Data for this cohort study were drawn from 2021 adult decedents from Kaiser Permanente Southern California and Colorado (n = 26,251). Caregivers of a decedent subgroup completed a postdeath care experience survey from July to August 2022 (n = 424). Measurements: SPC intensity (inpatient, outpatient, and home-based) and HO exposure in the five years before death were categorized as: (1) No SPC or HO; (2) SPC-only; (3) HO-only; and (4) SPC-HO. Timing of SPC exposure (<90 or 90+ days) before death was stratified by HO enrollment. Death in the hospital and potentially burdensome treatments in the last 14 days of life were extracted from electronic medical records (EMRs) and claims. EOL care experience was obtained from the caregiver survey. Results: Among the EMR cohort, exposure to SPC and HO were: No SPC or HO (38%), SPC-only (14%; of whom, 55% received inpatient SPC only), HO-only (20%), and SPC-HO (28%). For decedents who did not enroll in HO, exposure to SPC 90+ days versus <90 days before death was associated with lower risk of receiving potentially burdensome treatments (adjusted relative risk, aRR: 0.69 [95% confidence interval, CI: 0.62-0.76], p < 0.001) and 23% lower risk of dying in the hospital (aRR: 0.77 [95% CI: 0.73-0.81], p < 0.001). Caregivers of patients in the HO-only (aRR: 1.27 [95% CI: 0.98-1.63], p = 0.07) and SPC-HO cohorts (aRR: 1.19 [95% CI: 0.93-1.52], p = 0.18) tended to report more positive care experience compared to the no SPC or HO cohort. Conclusion: Earlier exposure to SPC was important in reducing potentially burdensome treatments and death in the hospital for decedents who did not enroll in HO. Increasing availability and access to community-based SPC is needed.