Palliative Medicine Physicians Research Articles

Integrating Palliative Medicine Physician Assistant in the Emergency Room

Integrating Palliative Medicine Physician Assistant in the Emergency Room

Primary Mental Health Competencies for Palliative Medicine Physicians: A Consensus-Prioritized List

Primary Mental Health Competencies for Palliative Medicine Physicians: A Consensus-Prioritized List

US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020

ContextDespite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings. ObjectivesTo examine changes in Medicare HPM physician workforce and their service delivery settings in 2008–2020. MethodsUsing the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in “Palliative Care and Hospice”. We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician. ResultsThe number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008–2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008–2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%. ConclusionDespite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas.

Abstract C001: A pilot study of palliadelic treatment with psilocybin to reduce psychological distress and improve quality of life in patients with advanced pancreatic adenocarcinoma

Abstract Background: Psychological distress is a common reaction to a cancer diagnosis and its treatment. Distress impacts quality of life, adherence to treatment, decision making and survival. Patients with pancreatic adenocarcinoma (PDAC) experience exceptionally high rates of psychological distress, most commonly depression, anxiety and suicidality. Psilocybin, a serotonergic psychedelic which is the active component in “magic mushrooms,” is a promising treatment for several mental health disorders. Prior studies in patients with cancer have combined a single dose of psilocybin with preparation and integration counseling and have shown significant, rapid and sustained improvement in depression, anxiety and quality of life. These studies have primarily been conducted in psychiatry or neuroscience clinics in heterogenous groups of patients, many of whom had completed cancer treatment. This study will evaluate the feasibility and safety of psilocybin-assisted therapy delivered in the outpatient palliative care clinic in patients with advanced PDAC who are receiving chemotherapy. Methods: This is a single center, open label pilot study of a psilocybin-assisted therapy integrated with palliative care in patients with advanced PDAC. The primary endpoints are the feasibility and safety of this strategy when integrated into routine palliative care. Secondary endpoints include short term changes in depression, anxiety and demoralization and changes in neuronal activity by functional MRI (fMRI). After 2-4 outpatient preparation sessions with a palliative medicine physician (PMP), the subject will take psilocybin (25mg capsule) at an individual session supported by a PMP and a trained mental health professional. Up to 3 integration sessions with a PMP will follow. Patient-reported measures of psychological distress and quality of life will be assessed at baseline, after the psilocybin dose and periodically during follow-up. Neuronal changes will be measured using fMRI before and after the psilocybin dose. Eligible patients are adults (ECOG 0-3) with advanced PDAC with adequate organ function. Patients with psychiatric conditions which preclude safe cessation of psychotropic drugs or requires hospitalization, a personal or family history of schizophrenia, psychotic disorder or bipolar disorder, who have a high risk of suicide or have serious or uncontrolled hypertension or cardiovascular disease are ineligible. Given the exploratory nature of the study, a formal statistical assessment of the sample size was not conducted. Twelve evaluable subjects will provide sufficient power to detect large effect sizes (Cohen’s d1.0) in the secondary endpoints. Wilcoxon signed rank test will determine the reduction in distress scores before and after the psilocybin session. Enrollment began in June 2023; two subjects have enrolled. The study is funded by the Jim Young Pancreatic Cancer Research Memorial Fund. Psilocybin is provided by Usona. ClinicalTrials.gov Identifier: NCT05220046 Citation Format: Kelsey A. Klute, Lou Lukas, Soonjo Hwang, Yeongjin Gwon, Mridula Krishnan, Jean Grem, Sunil Hingorani, Jody Koenig Kellas. A pilot study of palliadelic treatment with psilocybin to reduce psychological distress and improve quality of life in patients with advanced pancreatic adenocarcinoma [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr C001.

A Report on the Innovative University of Colorado Community Hospice and Palliative Medicine Fellowship.

Background: Predictive health services modeling signals a shortage of board-certified Hospice and Palliative Medicine (HPM) physicians. Methods: This article introduces the Community Hospice and Palliative Medicine (CHPM) Fellowship, an Accreditation Council for Graduate Medical Education (ACGME) Advancing Innovation in Residency Education (AIRE) project designed to enable mid-career physicians (at least five years out from residency or fellowship) to achieve eligibility for board certification in HPM. Results: From 2020 to 2023, 24 fellows have completed or are currently participating in the CHPM fellowship which is evaluated using the Kirkpatrick model. Conclusion: This program shows promise in addressing the impending HPM workforce shortage by allowing physicians to complete a fellowship in their local communities.

Development and validation of a questionnaire to explore preferences of patients, family caregivers, and kidney care providers on advance care planning in an end-stage kidney disease setting

Abstract Objectives To develop and validate an English and Kannada version of the questionnaire to assess awareness and knowledge of advance care planning (ACP) among end-stage kidney disease (ESKD) patients, caregivers, and healthcare providers. Methods The questionnaire was developed from the published literature on ACP use in ESKD setting after a literature search. An expert panel consisting of nephrologists, palliative medicine physicians, ESKD patients, and their family caregivers participated in the content validity of the questionnaire using the Delphi process. The study was conducted between August 2021 and July 2022 at a tertiary care hospital in India. A validated questionnaire was administered to eligible 30 ESKD patients, 30 caregivers, and 10 health care professionals. A retest was carried out 1 week after the first administration. Results The content validity ratio of patient, caregiver, and health care professions questions ranged from 0.6 to 1 and Cronbach’s α value was 0.737 to 0.925. The intraclass correlation coefficient values for the test–retest of all three sections of this questionnaire varied from 0.879 to 0.972. Significance of results The developed questionnaire is a reliable and valid method for assessing the preference and knowledge of ACP in ESKD patients, family caregivers, and kidney care providers both in English and Kannada.

Talking About Dying

This essay describes a palliative medicine physician’s experience with a dying patient and reflections on life.

An analysis of Plan, Do, Study, Act for a supportive care program for patients with metastatic breast cancer.

376 Background: Patients with metastatic cancer have unique survivorship needs. Recent studies show patients with advanced cancer have unmet needs in the following categories: health information (31%), psychosocial support (27%), symptom management and general wellness support (23%) (Hart, et al., 2022). The Living Well with Advanced Breast Cancer Clinic (LWABC) was established in 2017 to address these unmet needs. This multidisciplinary clinic provides the patient and caregiver(s) an individual visit with a medical oncologist, integrative medicine physician, palliative medicine physician, dietitian, and nurse navigator. The patient is provided in-depth education and personalized supportive care plans. Methods: Over recent years, clinic staff have utilized the Plan, Do, Study, Act (PDSA) (Taylor, et al., 2014 ) methodology to refine operations and improve patient care. In 2021, the plan phase was initiated with incorporation of a nurse navigator and program manager for the clinic. Nurse navigation services have been shown to improve patient and caregiver knowledge as well as quality of life and was deemed an important addition to the program (Oncology Nursing Society, 2018). At the beginning of calendar year 2022, in the “do” phase, the nurse navigator/program manager was hired and implemented pre-visit phone calls as well as navigation services for patients. These services include assessment of needs, patient education, provision of community resources, and assistance with scheduling referrals. At the beginning of calendar year 2023, use of the NCCN distress thermometer and problem list was initiated. The current phase, “study,” includes development of a dashboard for monitoring clinic operations. Review and assessment of distress thermometer data is ongoing. Results: When comparing calendar year 2021 to 2022, the clinic has seen increases in referrals (40 in 2021 to 65 in 2022), number of patients seen (31 in 2021 to 46 in 2022), and unique patient zip codes (28 in 2021 to 42 in 2022). There was also a reduction in late cancellation rates from 15.9% (2021) to 7.2% (2022). Late cancellation is defined as any appointment cancelled 24 hours or less prior to scheduled visit. Conclusions: Utilizing the PDSA cycle clinic staff have seen operational improvements over the last two years. Currently, this supportive care program remains in a “study” phase and will continue to evaluate progress and patient outcomes. Results from the act phase will be utilized to continue expansion of the clinic and services in the future. Further aiding this endeavor is an embedded patient advocate and ongoing outreach and collaboration with patient support organizations.

The Fall

In this narrative medicine essay, a palliative medicine physician learns firsthand how to listen to her mother’s end-of-life wishes amid the waves of loss and the noise of the treatment options being offered.

Over a third of palliative medicine physicians meet burnout criteria: Results from a survey study during the COVID-19 pandemic

Background: Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors influencing this among UK and Irish palliative medicine physicians is unknown. Aim: To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors. Design: Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel [MBI-HSS (MP)] and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life. Setting/participants: Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings. Results: There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31–40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002–0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62–0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75–49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p < 0.001). Conclusions: Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics.

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.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists.

Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists. The objective of this study was to develop EPAs for HAPC pharmacists. An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists. Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1). Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists.

Training community health workers to increase advanced care planning in African American women with breast cancer.

e18549 Background: Black women are more likely to be diagnosed with more aggressive subtypes of breast cancer, at more advanced stages, and have worse outcomes than white women. Rates of advanced care planning (ACP) discussions are lower among black patients with advanced cancer, and they are less likely to receive care concordant with their wishes at end of life. Community health workers (CHW) play a versatile role in bridging social barriers to care and offer a unique mechanism to improve ACP discussions in this population. The aim of our study was to use a mixed methods approach to examine current practices and strategies to facilitate integration of CHW in ACP with black women with breast cancer. Methods: Participants completed a 22-item questionnaire to assess prior training in ACP and experience serving cancer patients. Focus groups were conducted with CHW (N = 5) and providers (i.e., oncologists, radiation oncologists, and palliative medicine physicians; N = 6) to discuss knowledge of ACP, barriers to ACP discussions, strategies to integrate CHW into ACP, and components of an effective ACP training curriculum for CHW. Focus groups were transcribed and two independent coders analyzed the data using the Framework method to extract themes and components of an ACP training curriculum for CHW. Results: Approximately 60% of CHW reported having received prior training in ACP. All providers reported primarily serving Black patients, and 66% self-reported low rates of ACP documentation (10-25%) among their patients. In the focus groups, CHW and providers described elements of effective ACP discussions as patient value-focused, multidisciplinary, timely, and empowering. Common barriers to ACP discussions identified by CHW included inexperience with ACP, unclear responsibility to initiate the discussion, and patient factors such as reluctance and complex social dynamics; providers identified issues of mistrust, historic injustice and power dynamics with their patients. Both CHW and providers viewed the role of CHW in ACP as a longitudinal process to empower, educate and reinforce patients’ values via a non-judgmental member of the community. For both groups, an ideal training curriculum teaches about key oncologic concepts, assesses patient readiness, and increases familiarity with ACP documentation. Conclusions: CHW serve a vital role in bridging care gaps for vulnerable patients and provide an opportunity to improve rates of ACP discussions in Black women with breast cancer. A training curriculum designed to help CHW assess a patient’s understanding of ACP and reinforce a longitudinal conversation is feasible, straightforward and can be incorporated into CHW workflow. One such training curriculum could expose CHW to different ACP documents, provide simulated patient encounters, and educate CHW on verbal and non-verbal cues from providers that may signal an ACP discussion is needed.

Mid-Career Training to Advance Palliative Care.

The demand for specialist palliative medicine physicians, advanced practice providers, and other team members outstrips supply. Traditional paths to specialty practice will not meet projected need. Therefore, innovation and research are required. One innovation is the training of midcareer professionals; those who have been in practice and want to change to palliative care. Barriers to leaving practice and returning to traditional training are high; not the least of which is the opportunity cost. In this roundtable, experts discuss what they have learned from current research, and point the way to additional needed research.

Ethics of sedation for existential suffering: palliative medicine physician perceptions - qualitative study

ObjectivesPalliative sedation for existential suffering (PS-ES) is considered a controversial practice to control refractory suffering at the end of life. This study aims to explore Belgian palliative care physicians’ perceptions...

Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis

ContextThe goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized. ObjectiveTo identify and characterize differing conceptualizations of the GOCD. MethodsCritical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians. ResultsGOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians. ConclusionThese findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.

Our Best Judgment

In this narrative medicine essay, a palliative medicine physician describes his brother's hospitalization and death from COVID-19. He reflects on his brother's ability to achieve a dignified death because the physicians caring for him honestly assessed his prognosis.

Commentary on The Listening.

Commentary on The Listening.

Why I despair at being a palliative medicine physician.

Why I despair at being a palliative medicine physician.

Creation of Individualized Care Plans in High Risk Oncology Patients: A Team Based Model to Decrease Unnecessary Hospitalizations and ED Utilization

BACKGROUNDReducing unplanned hospital readmissions, defined as a hospitalization occurring within 30 days of discharge, is a national policy priority that is aimed at improving health care quality. Unplanned hospitalizations and emergency department visits are a major problem in medical oncology patients. In our cancer institute, just 6% of all discharged patients accounted for > 40% of unplanned readmissions. These patients continue to be highest risk of future admissions, ICU stay, ED visits, over use of chemotherapy and underuse of hospice resources. We hypothesized that developing individualized care plans (ICP) for patients with the highest preventable utilization will better address the complex needs of this patient population and subsequently decrease preventable admissions, readmissions, and ED visits. METHODSAn Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, advanced practice providers and nurses. On a bimonthly basis, adult patients (>18) with at least two unplanned hospital readmissions during the previous 60 days were identified. Hospitalizations for planned chemotherapy were excluded, along with patients who have already been referred to hospice or have since been deceased. All other patients otherwise were included. The identified patients were then reviewed by the ICT to identify opportunities specific to the needs of each patient. ICPs were then created using a team-based approach with parallel input from the patients' primary outpatient oncology providers. These recommendations were then communicated to applicable providers to be implemented. RESULTS226 hospitalizations, and 163 ED visits for 36 individual high-risk patients were evaluated. All of the patients had relapsed/refractory hematological malignancy or metastatic solid tumor disease. Median age was 55.2 with a range of 20-74. 50% of the patients were female. 42% of the patients had a primary diagnosis of a hematological malignancy, while 58% had an underlying solid tumor malignancy. 22.2% of the patients had gastrointestinal malignancy, 19.4% of the patients had acute leukemia, and 13.9% of the patients had an aggressive lymphoma.After implementation of ICP, hospitalizations decreased from 0.89 per patient month (ppm) to 0.36 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days.On further analysis, patients with hematological malignancies (HM) had an average hospitalization of 0.89 ppm which decreased to 0.48, while solid tumor patients (ST) had a decrease from 0.87 to 0.27 ppm. Average readmissions ppm reduced from 0.4 to 0.28 in patients with HM while it reduced from 0.445 to 0.03 in ST. Average length of stay before ICP was 8.48 days vs 10.2 days in MH vs ST, which changed to 6.16 and 2.55 days respectively after ICP. As seen in table 2b, there was not a consistent change in all metrics in HM compared to ST. CONCLUSIONCreation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay in all disease groups, but ST patients seemed to have a greater impact than in HM patients. The selection process and the interventions from the multidisciplinary group were able to identify and significantly improve overall utilizations in the ST cohort, but in order to achieve the same effect a more selective process may be required in HM patients. Given the difference in biology of the diseases and expected management and side effects of treatment, HM patient cohort benefitted less as a cohort in this study. A more selective process in the HM patients to only include patients >100 days from hematopoietic stem cell transplant, and excluding patients undergoing curative management with induction/consolidation therapy may better isolate the cohort best suited to benefit from this ICT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.