Palliative Research Articles

Behavioral health needs are highly prevalent among individuals receiving long-term services and supports (LTSS), yet palliative care (PC) models in these settings often underemphasize psychiatric symptom management. This study explores interdisciplinary staff perspectives on behavioral health as a core domain of PC across nursing home and Program of All-Inclusive Care for the Elderly (PACE) sites. We conducted a secondary analysis of a multi-site survey assessing PC needs across 13 LTSS sites within a large health system in New York State. We examined 5 survey items related to psychiatric symptom management, analyzing frequency, comfort, perceived benefit, and training interest. Multivariable logistic regression was used to assess associations between staff characteristics and behavioral health-related outcomes. Among 597 respondents, 60.5% reported that over half of their patients could benefit from psychiatric symptom management, and nearly half (49.2%) reported managing such symptoms weekly or more. Forty percent identified psychiatric symptom management as one of the top three ways PC specialists could help their patients, and 44.6% expressed interest in further behavioral health training as part of further PC training. Prior professional experience with PC was associated with greater recognition of behavioral health needs among patients (aOR 1.6), greater likelihood of managing psychiatric symptoms (aOR 2.0), and greater comfort doing so (aOR 1.5). Behavioral health emerged as a salient and frequently encountered domain of serious illness care among LTSS staff, particularly in nursing home and PACE settings. Staff with prior PC experience were more engaged and confident in addressing psychiatric symptoms. Findings underscore the need for PC models in LTSS to better integrate behavioral health - through training, interdisciplinary collaboration, and care delivery redesign - to meet the complex needs of medically and psychiatrically vulnerable populations.

Background: Palliative care is increasingly recognized for its role in advanced heart failure management, yet its real-world impact on healthcare utilization and clinical outcomes remains underexplored. This study evaluates the association of inpatient palliative care consultation with readmission rates, hospital resource use, and mortality among patients hospitalized for end-stage heart failure (ICD code I50.84). Research Question: Is inpatient palliative care consultation for end-stage heart failure patients significantly associated with readmission rates, hospital resources, and mortality? Methods: A retrospective cohort analysis was conducted using the 2022 Nationwide Readmissions Database (NRD). Among 21,716 patients hospitalized with end-stage heart failure, 15,968 (73.5%) did not receive palliative care, while 5,748 (26.5%) did. Propensity score matching (1:1 nearest neighbor without replacement) yielded a matched cohort of 5,678 in each group. Outcomes assessed included 30-day readmission, length of stay (LOS), total hospital charges, and in-hospital mortality. Data analysis was conducted using STATA 19 (StataCorp LLC, College Station, TX). P value <0.05 was considered significant. Results: In the matched cohort, palliative care was associated with significantly lower 30-day readmission rates (3.5% vs. 6.2%, p < 0.001), representing an absolute risk reduction of 2.7% (Z = 6.32, 95% CI: 1.84%–3.59%). Median LOS was modestly longer among palliative patients (8 vs. 7 days; p < 0.0001), while median total charges were comparable ($74,747 vs. $71,391; p = 0.704). In-hospital mortality was markedly higher in the palliative group (33.1% vs. 6.8%, p < 0.001), reflecting end-of-life care decisions. Comorbidities more common in palliative patients included atrial fibrillation, chronic kidney disease, and prior myocardial infarction. Non-palliative patients had higher rates of obesity, tobacco use, and drug abuse. Conclusion: Palliative care in end-stage heart failure was associated with reduced readmissions, comparable hospital costs, and expectedly higher in-hospital mortality. These findings suggest that integrating palliative care into the management of advanced heart failure offers meaningful clinical care without compromising the hospital’s economic investments, which allows clinicians to optimize end-of-life care.

Introduction: Peripheral artery disease (PAD) is associated with high morbidity and mortality, yet palliative care (PC), a supportive, team-based approach integrated remains underutilized. This review contrasted PC components, patient-level and program outcomes, and patient-reported outcomes across heart failure (HF), coronary artery disease (CAD), and peripheral artery disease (PAD). Methods: We searched PubMed and Cochrane databases for English-language studies published from January 1, 2014, to December 19, 2024. Studies included systematic reviews and original investigations of PC interventions in HF, CAD, and PAD. The ROBIS tool was used for quality appraisal. Data were synthesized across seven domains: (1) symptom management, (2) advance care planning (ACP), (3) psychosocial/spiritual support, (4) quality-of-life measurement (QoL), (5) interdisciplinary team integration, (6) referral timing and triggers, and (7) sustainability of care. Results: Fifty-six studies were included (HF: n=48; PAD: n=5; CAD: n=2; HF+CAD: n=1), including randomized trials, meta-analyses, and observational studies. HF studies focused on patients with New York Heart Association (NYHA) Class II–IV and high comorbidity burden, across in- and outpatient settings. PAD studies included patients with chronic limb-threatening ischemia; CAD populations were post-MI or post-revascularization. HF programs used validated QoL tools (e.g., ESAS, KCCQ, EQ-5D) to guide symptom management and referrals. ACP was a central feature of HF interventions, contributing to improved documentation, reduced hospital utilization, and care alignment. In contrast, PAD studies mostly lacked standardized assessment tools and relied on clinical outcomes (e.g., readmissions, complications, mortality). ACP was limited to end-of-life contexts without continuity. Psychosocial and spiritual support services were rarely addressed. CAD studies utilized general and disease-specific QoL instruments (SF-36, Seattle Angina Questionnaire), and focused on education and rehabilitation with minimal PC integration. ACP was rarely emphasized, psychosocial/spiritual support was excluded, and PC referrals for CAD patients were late and lacked continuity. Conclusion: HF programs provide a transferable template for PAD, based on an early, structured and multidisciplinary PC. This could lead to a PAD-specific care model that integrates best practices from HF and that helps address underuse in a vulnerable and overlooked population.

Introduction: Post-myocardial infarction ventricular septal defect (MI-VSD) is a rare, often fatal complication of MI, regardless of treatment approach. Presentations vary from new murmurs to acute cardiogenic shock. This case describes a patient with delayed MI presentation complicated by ventricular rupture. Case Presentation: An 81-year-old woman with B-cell lymphoma, emphysema, and autoimmune hepatitis presented with progressive dyspnea and cough. Initially treated for an upper respiratory infection, she deteriorated and arrived in SCAI C cardiogenic shock. She was hypoxemic on high-flow nasal cannula; blood gas showed severe acidosis and lactate of 13.9 mmol/L. Exam revealed bibasilar rales, cool mottled extremities, and no murmur. ECG showed tachycardia with new anterolateral Q waves and ST elevation in V2–V5, prompting STEMI activation. Bedside echo showed apical and inferoseptal akinesis. Coronary angiography was deferred due to delayed presentation and down-trending high-sensitivity troponin (618 ng/L). She was admitted to the CCU, where shock improved with norepinephrine, milrinone, and IV diuresis. Her course was complicated by new-onset atrial fibrillation with RVR. Despite IV amiodarone, RVR persisted, along with worsening respiratory status and increasing vasopressors needs. Limited echocardiography revealed basal hypercontractility and dynamic LV outflow tract obstruction (LVOTO). Esmolol was considered to reduce the gradient. Simultaneously, pulmonary artery catheter readings suggested new left-to-right shunting. A new loud holosystolic murmur was heard, and repeat echocardiogram confirmed a large ventricular septal rupture (VSR). Per the patient’s prior wishes, surgical intervention was deferred. Palliative care was initiated, and the patient passed away comfortably. Discussion: This case underscores the importance of vigilance for both arrhythmogenic and mechanical complications in late-presenting, un-revascularized MI. The presence of dual complications—dynamic LVOTO and VSR—illustrates the clinical complexity. This case also highlights key decision points regarding temporary mechanical circulatory support and the need to weigh aggressive interventions against patient goals in frail, multi-morbid individuals, where benefit to quality of life and survival may be limited.

Introduction: Religiosity is a core component of palliative care and whose roles in patients with cancer were described. However, there is a paucity of studies in cardiovascular disease (CVD). Hypothesis: Religiosity can alleviate the symptoms of CVD patients in end-of-life (EOL). Aims: To clarify the influence of religiosity on physical symptoms, quality of care (QOC) and quality of death (QOD) in EOL care for CVD patients. Methods: We conducted a nationwide cross-sectional mortality follow-back survey using a questionnaire for bereaved caregivers of patients who had died of CVD in Japan. Measurements included Memorial Symptom Assessment Scale (MSAS), Care Evaluation Scale (CES) and Good Death Inventory (GDI). We assessed each outcome by the presence of religiosity. Results: Of the questionnaire distributed to 15,047 descendants, we finally analyzed 4,436 responses about religiosity. 795 (17.9%) descendants answered that patients had been supported by religion 1 month before death. The religion-supported group was older (Religion: 88.9±8.7 vs. No Religion: 86.7±9.4, P<0.001), more frequent in females (70.9% vs. 60.3%, P<0.001), less frequently stayed at hospital 1 months before death (15.8% vs. 24.0%, P<0.001), and significantly more likely to report having fewer symptoms in MSAS sub-score and being more satisfied in CES and GDI sub-score. The results were the same except for “Lack of energy” and “Nausea” in MSAS after adjusting the confounders. The total mean score of CES and GDI was also significantly higher in the religion-supported group (69.2±21.9 vs. 63.6±24.2, P<0.001, 65.4±17.0 vs. 53.7±22.1, P<0.001, respectively). Conclusion: Religiosity could benefit CVD patients in EOL care by reducing physical symptoms and improving QOC and QOD.

Background: Heart failure (HF) continues to be a major cause of morbidity and mortality worldwide, placing a significant burden on healthcare systems. Differences in the outcomes of HF hospitalizations for adults in teaching vs. non-teaching hospitals in urban settings are uncertain. Research Question: Do outcomes of HF hospitalizations differ between patients hospitalized in urban teaching vs. non-teaching hospitals in the United States? Methods: HF hospitalizations were abstracted from the 2016 through 2022 Nationwide Readmissions Database and stratified into urban teaching vs. urban non-teaching hospital settings. Propensity-score matching was used to control for baseline differences between teaching and non-teaching hospital cohorts. Logistic regression and lognormal models were estimated to assess differences in inpatient mortality, length of stay (LOS), total costs, complications, and 30-day and 90-day all-cause readmissions. Odds ratios (OR) with associated 95% Confidence intervals (CI) and p-values were reported. Analyses were conducted via SAS v. 9.4. Results: A total of 7,558,299 weighted HF hospitalizations were included in the analysis, of which 76.3% involved urban teaching hospitalizations. Compared to urban non-teaching, HF hospitalizations in urban teaching hospitals were associated with higher odds of in-hospital mortality (OR 1.24, 95% CI:1.21-1.27); had higher complications, including cardiogenic shock (OR 2.58, 95% CI, 2.46, 2.70), cardiac arrest (OR 1.31, 95% CI, 1.27, 1.36), CPR (OR 1.28, 95% CI, 1.22, 1.34), and use of extracorporeal membrane oxygenation (OR 20.13, 95% CI, 13.0, 31.2), intra-aortic balloon pump (OR 4.46, 95% CI, 3.90, 5.10) and mechanical ventilation (OR 1.27, 95% CI, 1.23, 1.33); higher hospitalization cost (Ratio 1.18, 95% CI: 1.17,1.20), longer length of stay (OR 1.16, 95% CI: 1.15, 1.17) and a greater palliative care consultation rate (Ratio 1.35 (95% CI 1.30, 1.40) (all p<0.001) ( Figure 1 ). 30-day (OR 1.03, 95% CI: 1.02, 1.04) and 90-day (OR 1.05, 95% CI: 1.02, 1.07) all-cause readmission rates were also statistically higher (p<0.001), though the difference was clinically non-significant ( Figure 2 ). The home discharge rate was similar for teaching and non-teaching hospitals ( Figure 2 ). Conclusion: HF hospitalizations in urban teaching hospitals were associated with higher inpatient mortality, complication rates, resource utilization, and palliative care consult rates than urban non-teaching hospitals.

Background: The prevalence of peripheral arterial disease, including chronic limb-threatening ischemia (CLTI), is globally increasing due to the aging society and the pandemics of diabetes mellitus. Although managing elderly CLTI patients with non-ambulatory status is substantially common in clinical practice, determination of treatment planning remains clinically challenging. This study aimed to evaluate the mortality and prognostic factors in elderly CLTI patients with non-ambulatory. Methods: This was a multicenter retrospective observational study enrolling 2309 CLTI patients (age: 75.5 ± 10.2 years, male: 60.5%, diabetes mellitus: 61.9%, dialysis: 46.9%) who underwent endovascular therapy (EVT) between April 2010 and March 2024. Patients aged over 80 years old with non-ambulatory status including wheelchair or bedridden were defined as the vulnerable CLTI group. The primary outcome measure was all-cause mortality, and were analyzed by multivariate analysis. Results: A total of 443 patients (19.2%) were classified as vulnerable CLTI. The 5-year all-cause mortality rate was 76.4% in the vulnerable CLTI group and 49.9% in the non-vulnerable CLTI group (p<0.001). The multivariate analysis revealed hemodialysis (hazard ratio [HR]: 1.83, p < 0.001), wound, ischemia, and foot infection (WIfI) stage 4 (HR: 1.71, p = 0.002), left ventricular ejection fraction < 50% (HR: 1.52, p = 0.04), and serum albumin level < 3 g/dL (HR: 1.55, p = 0.009) were positively associated with mortality in vulnerable CLTI group, with no significant interactions. 12-month mortality rate was 71.6% in patients with three or more of these risk factors. Conclusions: The current study revealed that hemodialysis, wound severity, malnutrition, and cardiac dysfunction were significantly associated with mortality in vulnerable CLTI patients. Risk stratification based on these predictors allows estimation of prognosis in vulnerable CLTI patients, and would be clinically useful for determination of treatment planning including palliative care.

Introduction: Elective withdrawal of non-invasive ventilation (NIV) in motor neurone disease (MND) is recognised as impactful on clinician’s mental health and well-being, presenting complex ethical, legal, and emotional challenges [1,2]. To reduce the emotional burden on staff, we designed and delivered an immersive simulation-based training day aimed at improving clinical confidence in managing elective NIV withdrawal and its holistic challenges. Methods: Nine Palliative care registrars participated in a structured educational intervention combining classroom-based teaching with immersive simulation scenarios reflecting real-world cases. Participants self-rated their confidence in four key domains—ethical understanding, legal knowledge, practical implementation, and communication—at three intervals: before the session, after the classroom component, and post-simulation. The simulation occurred in a high-fidelity immersive environment reflecting a domiciliary setting enhanced by high quality acting to support challenging conversations. A manikin was used which can display eye blinking, carotid pulse, chest wall movement, radial pulse, sub cutaneous administration of medicines. Results: Baseline confidence of “Not confident at all” was lowest in practical implementation (57%) and communication (14.3%). After the classroom session, “very confident” responses rose to 83.3% in ethical and 75% in legal domains, while practical and communication confidence saw modest increases. Following simulation, confidence in ethical, legal, and practical domains rose to 88.9%. Communication skills confidence rose to 66.7%, a 52.4 percentage point increase from baseline (Figure 1). Discussion: This blended educational approach—combining theoretical teaching with immersive simulation—significantly enhanced participant confidence in managing the elective withdrawal of NIV in MND than just classroom-based teaching alone. Simulation was particularly effective in reinforcing practical and communication skills, underlining its value in preparing clinicians for ethically complex, emotionally charged scenarios. It is hoped that this experience will positively impact clinician’s mental health and well-being for future ‘real life’ experiences. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable

When Autonomy Fails: Ethics, Philosophy, and the Legal Duty of Palliative Care - Reflections on End-of-Life Medicine in the 21st Century.

Introduction: Milrinone and dobutamine are commonly used inotropes for advanced heart failure, but comparative data in patients without renal dysfunction are limited. Prior studies rarely focus on this subgroup and often lack real-world representation or adjustment for comorbidities and lab parameters. This study uses a multi-institutional, real-world database to compare short- and long-term outcomes of these agents in patients with end-stage heart failure and preserved renal function. Hypothesis: In patients with end-stage heart failure and preserved renal function, milrinone use is associated with lower mortality but a differing arrhythmia risk compared to dobutamine. Methods: We conducted a retrospective cohort study using the TriNetX Research Network. Hospitalized patients with end-stage heart failure who received either milrinone or dobutamine were included. Exclusions were: use of both agents during index hospitalization, eGFR <60, AKI, CKD stage 3–5, prior transplant, mechanical circulatory support, or documented palliative care. Propensity score matching (1:1) was applied across demographics, comorbidities, medications, and lab/clinical parameters. Outcomes included all-cause mortality and atrial/ventricular arrhythmias over 30-day, 1-year, and 5-year windows. Patients were excluded from each outcome analysis if the outcome occurred prior to the index event. Results: Post-matching, 6,051 patients were included per cohort. Thirty-day mortality was lower with milrinone (414/6,035) than dobutamine (587/6,014), RR 0.703 (95% CI: 0.623–0.793). At 1 year, mortality was 1,159 vs. 1,378 (RR 0.838; 95% CI: 0.782–0.898). At 5 years, mortality was 1,993 vs. 2,110 (RR 0.941; 95% CI: 0.896–0.989). Milrinone was associated with higher arrhythmia incidence at 1 year (RR 1.125; 95% CI: 1.008–1.255) and 5 years (RR 1.121; 95% CI: 1.036–1.212), but not at 30 days. Conclusion: In patients with end-stage heart failure and preserved renal function, milrinone was associated with lower all-cause mortality but increased arrhythmia risk over longer follow-up. These findings indicate that there may be underlying outcome differences between inotropic choices for certain patient populations, and prospective trials are warranted.

Introduction/Background: Cardiac arrest caused >9M U.S. adult deaths (1999–2024). Place of death reflects end-of-life care quality. While home/hospice deaths rose for other conditions, cardiac arrest patterns by demographics remain understudied. Research Questions/Hypothesis: Death location varies by demographics, with younger/minority patients more likely to die in EDs and less likely in hospice than older White patients. Methods/Approach: From CDC WONDER, we extracted all U.S. adult (≥25 y) deaths attributed to cardiac arrest (ICD-10 I46) from 1999–2021. Place of death was categorized as inpatient (ref), ED/outpatient, home, hospice/nursing, or other. Crude ORs (95% CIs) comparing each non-inpatient location to inpatient were computed via 2×2 tables, stratified by age (25–44, 45–64, 65–84 [ref], ≥85), sex (male [ref], female), race (White [ref], Black, AI/PI), Hispanic origin (non-Hispanic [ref], Hispanic), and urbanization (large metro [ref], medium/small metro, rural Results/Data: Overall, 41.2% died in hospital; 11.1% in outpatient/ED; 22.5% at home; 20.5% in hospice/nursing; 4.6% elsewhere. Compared with 65–84, 25–44 showed lower home (OR 0.58; 95% CI 0.57–0.58; P<0.001) and hospice (OR 0.20; 95% CI 0.18–0.22; P<0.001), but higher ED (OR 1.08; 95% CI 1.07–1.09; P<0.001). Conversely, ≥85 had higher home (OR 1.39; 95% CI 1.38–1.39; P<0.001) and hospice (OR 2.96; 95% CI 2.95–2.97; P<0.001), but lower ED (OR 0.82; 95% CI 0.81–0.82; P<0.001). Females had higher home (OR 1.02; 95% CI 1.02–1.03; P<0.001) and hospice (OR 1.74; 95% CI 1.73–1.74; P<0.001), but lower ED (OR 0.79; 95% CI 0.79–0.80; P<0.001). Blacks had lower home (OR 0.61; 95% CI 0.61–0.62; P<0.001) and hospice (OR 0.55; 95% CI 0.55–0.55; P<0.001), but higher ED (OR 1.13; 95% CI 1.12–1.14; P<0.001) versus Whites. Hispanics had lower home (OR 0.82; 95% CI 0.82–0.83; P<0.001), ED (OR 0.69; 95% CI 0.69–0.70; P<0.001), and hospice (OR 0.56; 95% CI 0.56–0.56; P<0.001) than non-Hispanics. Rural decedents had higher home (OR 1.26; 95% CI 1.25–1.26; P<0.001), ED (OR 1.59; 95% CI 1.58–1.60; P<0.001), and hospice (OR 1.09; 95% CI 1.09–1.10; P<0.001) versus large-metro. Conclusion(s): Only 41% died in hospital. Young adults had higher ED deaths; ≥ 85 and women had more home/hospice deaths. Blacks, Hispanics, and rural groups faced lower home/hospice and higher ED mortality, warranting equitable palliative care interventions.

Background/Objectives: Identifying patients with palliative care needs can be challenging in clinical practice. This study reports on the tailoring and evaluation of a minimally invasive intervention (MINI) to support early planning of palliative care in acute hospitals. The MINI includes the Surprise Question (SQ) and the Supportive and Palliative Care Indicators Tool (SPICTTM) for health and social care professionals, as well as a patient Question Prompt Sheet. Methods: A multi-method intervention study was conducted, including interviews and a pre–post survey of professionals on the development, implementation, and experiences with MINI. Interview data were analyzed inductively and survey data descriptively. Results: Data from 44 participants were included. MINI was generally considered acceptable and relevant, particularly the SQ, which prompted reflection among staff. Following the intervention, a significant improvement was observed in the presentation of regional specialist palliative care services for patients, as well as in the identification of psychosocial problems and their discussion with patients and relatives. While physicians reported increased confidence in initiating end-of-life conversations, other hospital staff showed mixed responses. Reported barriers for implementing MINI included limited time, the COVID-19 pandemic, staff strikes, emotional burden, and unclear responsibilities, indicating a low level of commitment. SPICT use was inconsistent, suggesting low integration into workflows. Interprofessional collaboration improved, particularly with external palliative care providers. Sustainability was hindered by a lack of institutional support, ongoing training, and formal routines. Conclusions: MINI may have the potential to shift the focus away from purely curative approaches. However, to guarantee success, future studies should ensure better alignment between intervention design, implementation and framework conditions.

BackgroundPrimary healthcare services provide care to patients and their relatives during the late palliative phase in the patients’ home or in facilities such as nursing homes. Patients receiving palliative care may be vulnerable due to the total pain of the situation they are facing, which requires great expertise of healthcare professionals in meeting the patients’ needs. The aim in this study was to explore patients’ experiences of quality in palliative care and advance care planning in primary healthcare services.MethodsThis study has a qualitative design. Five patients in the late palliative phase in primary care from different municipalities in Norway participated. All participants had experiences across both primary and specialist care settings. Individual interviews were conducted between January 2022 and July 2023. The interviews were transcribed verbatim and analysed using content analysis. The study adheres to the checklist of the consolidated criteria for reporting qualitative research.ResultsThe findings are described in terms of four main themes: (1) trust in supportive clinicians to ease their future path, (2) perceived quality of palliative care depended on the context, (3) advance care planning helped to tidy up important aspects of life, and (4) personalized family support and involvement eased burdens for patients and relatives.ConclusionPatients in late palliative phase and their experiences of palliative care highlight the need for information and support from healthcare professionals, but the organization of primary healthcare settings does not adequately address these needs. A key aspect of quality in care is comprehensive and individualized follow-up throughout the patient’s illness trajectory. Another area that affects the quality of palliative care is the communication skills of healthcare professionals. Care plans for the end- of -life were developed through advance care planning, but the quality of implementation varied in home care. A huge concern for patients in the late palliative phase was if and how their relatives received the support they needed.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12904-025-01919-8.

IntroductionHeart failure (HF) patients experience significant palliative care needs (PCN), which can be assessed using the Integrated Palliative Care Outcome Scale (IPOS). This study evaluates PCN in hospitalized HF patients and their association with patient characteristics and mortality.Population and methodsA prospective observational study was conducted on 160 hospitalized HF patients in Vietnam. PCN were assessed using IPOS (17 questions, scored 0–4, none to severe). PCN was defined as ≥ 2 items scoring 4 or ≥ 3 items scoring ≥ 3. All-cause mortality was tracked post-discharge. ResultsPCN were identified in 59.4% of patients, with shortness of breath (57.5%), weakness (51.9%), and pain (45.6%) being the most common symptoms at moderate severity. PCN correlated with longer HF duration, lower eGFR, and specific medication use (intravenous drugs, RAAS inhibitors, MRAs). PCN independently predicted higher post-discharge mortality (adjusted HR: 2.63, 95% CI 1.06–6.53, p=0.037).ConclusionPCN are prevalent in hospitalized HF patients and independently associated with increased mortality, underscoring the need for routine PCN assessment and early palliative care integration.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12904-025-01897-x.

Radiotherapy remains crucial to the management of gynecologic cancers. This review highlights recent advances in radiation delivery, integration with systemic therapies, and the evolving role of radiotherapy across definitive, adjuvant, recurrent, and palliative settings. Trials in cervical cancer have established survival gains with novel systemic combinations, while adaptive and standardized radiation protocols continue to improve precision and outcomes. In endometrial cancer, molecular classification is informing adjuvant therapy selection and driving subtype-specific clinical trials. Expanding use of stereotactic body radiotherapy and proton therapy in ovarian and recurrent disease demonstrates feasibility and durable control. Efforts in reirradiation, palliative care, and survivorship underscore the need for safe dose escalation, symptom management, and long-term quality of life research. Persistent disparities and rising costs emphasize the importance of value-based and equitable care delivery. Emerging imaging and adaptive techniques are making radiation for gynecologic cancers more precise and individualized. Advances in brachytherapy, stereotactic approaches, and proton therapy are refining delivery, while integration with systemic and molecularly guided strategies is broadening therapeutic impact. Ongoing priorities include reducing disparities, improving survivorship, and translating technological progress into accessible, patient-centered care.

BackgroundOpioid use is associated with increased health care service utilization but home care recipients and patients with dementia have been mostly ignored in earlier studies, although changes in their health status can have dramatic cost consequences. This study examined social and health care utilization and costs among older home care recipients before and after opioid initiation, with persons with dementia as a subgroup of interest.MethodsThis retrospective nationwide register-linkage study included Finnish regular home care recipients aged ≥ 65 years with opioid initiation between 1st March 2015 and 31st December 2016. Recipients with health care contacts due to cancer and palliative care were excluded.Incidence rate ratios of social and health care service use during the observation period starting one year before and ending one year after opioid initiation were calculated using nationwide register data. The utilization costs of various social and health care service categories were compared before and after the opioid initiation. Recipients with and without dementia were analysed separately.ResultsHome care recipients had 1.76 (95% CI 1.75 − 1.78) times more inpatient days, 1.31 (1.26 − 1.36) times more emergency care admissions, and recipients without dementia had more outpatient service use (secondary care 1.10 [1.06 − 1.13], primary care 1.06 [1.04 − 1.07]) after opioid initiation compared to the preceding year. Home care service use decreased (0.85 [0.85 − 0.85]) in recipients with dementia but increased in those without (1.08 [1.08 − 1.08]). Of the recipients, 20.8% were admitted to long-term residential care during the follow-up year. The mean annual total costs per recipient were 21% higher during the year following opioid initiation compared to the preceding year. A peak in the costs, consisting largely of inpatient costs, was observed about a month before opioid initiation, after which costs showed a declining trend but remained above the baseline level.ConclusionsRecipients’ monthly health care resource use started to increase already before opioid initiation, after which monthly expenditures declined steadily, which may reflect mostly recipients’ worsened health status before opioid initiation. Most of the expenditures arose from housing services. The relationship between opioid use and utilization of residential care and home care services should be further examined.Trial registrationNot applicable (a retrospective register-based study).Supplementary InformationThe online version contains supplementary material available at 10.1186/s12877-025-06550-z.

Equitable and effective service and policy decisions require reliable evidence-based information; interRAI assessments offer objective data across broad health determinants for multiple purposes. This article aims to highlight selected embedded scales and algorithms and illustrate their prevalence across settings using Canadian data. Ten measures are described along with examples of subsequent use in predicting outcomes, adverse events, and resource utilization across diverse populations and jurisdictions. Prevalence rates for nine scales and algorithms were available across home and community care, Long Term Care (LTC), and inpatient settings. Higher rates of disability in function and cognition were seen in LTC and CCC, whereas palliative care has highest prevalence of health instability. Overlaps in key areas suggest the need to provide targeted services irrespective of setting. Overall, this article highlights the potential of scales and algorithms to capture key clinical information across the broader health determinants while minimizing assessment burden.

Discontinuing active oncological treatment and initiating palliative care is a critical moment in cancer care, requiring oncologists to address complex clinical, ethical, and emotional challenges. This narrative review aims to provide clinicians with practical guidance for conducting conversations about treatment discontinuation and transitioning patients to palliative or hospice care. Drawing from current clinical guidelines, empirical research, and expert perspectives, the article reviews evidence-based communication strategies and frameworks, including the SPIKES protocol, Ask–Tell–Ask, the WHO model, and the disclosure model. The article also explores the clinical, functional, psychosocial, and ethical criteria relevant to treatment withdrawal decisions, as well as the timing and structure of end-of-life discussions. A practical algorithm is proposed, synthesizing key principles into a step-by-step guide for use in daily oncology practice. The algorithm supports clinicians in balancing medical indications with patient values and preferences, fostering shared decision-making and maintaining therapeutic relationships even in the most difficult circumstances. The review concludes that structured yet flexible communication enhances patient understanding, reduces unnecessary interventions, and improves the quality of end-of-life care. By promoting patient-centered care and timely palliative integration, this article offers oncologists a clear and adaptable approach to one of the most sensitive aspects of cancer care.

Pain control in palliative care

This work encompasses both a review article and the proposal of an operational model for the implementation of advance directives in older adults with terminal or end-stage illnesses within the Geriatrics Department, conceived as an ethical and clinical strategy aimed at promoting autonomy at the end of life. Through a comprehensive regulatory, bioethical, and epidemiological review, as well as an analysis of institutional barriers, we developed an algorithm that includes candidate identification, provision of information to patients and their families, obtaining informed consent, formalization of the document, registration, and ongoing follow-up. The methodology was grounded in the integration of national and international evidence, the clinical experience of the team, and current Mexican legislation. Our proposal seeks to foster shared anticipatory decision-making, reduce futile interventions, and humanize the dying process. We conclude that the institutionalization of clear protocols regarding advance directives enhances the quality of palliative care, facilitates proactive planning, decreases family conflicts, and strengthens respect for the dignity of older adults.