Emily Chai

Effect of Palliative Care–Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial

IMPORTANCE Family caregivers of patients with chronic critical illness experience significant psychological distress. OBJECTIVE To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes. INTERVENTIONS At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. MAIN OUTCOMES AND MEASURES The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival. RESULTS Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different. CONCLUSIONS AND RELEVANCE Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01230099.

Managing Pain in the Elderly Population: Pearls and Pitfalls

While pain is a common symptom among older adults, it often is underdiagnosed and undertreated. Aging-related physiological changes, misperceptions about the use of pain medications by both patients and providers, and the lack of evidence-based clinical research on pain management in older adults are some of the reasons why pain in older adults is mismanaged. Using extrapolated evidence from pain research in younger patients, consensus statements, and best practice guidelines, this article summarizes and highlights areas of geriatric pain assessment and management that need special consideration. Some highlighted areas include 1) pain assessment in cognitively impaired patients; 2) medication choice and initiation doses; 3) duration of adequate medication trials; and 4) common medication side effects and suggested management.

Integrating Palliative Care Into Primary Care

Patients with serious illnesses are living longer and with greater disabilities. Palliative-care interventions have been shown to increase quality of life, lower costs, and improve survival. In order to meet the palliative-care needs of patients, it is crucial for primary-care clinicians to understand how they can provide primary palliative care and when they should refer to palliative-care specialists. By working together, many more patients and families will receive the comprehensive, individualized, coordinated care and support that both primary care and palliative care offers to patients. This article will review literature illustrating the benefits of palliative care; discuss why primary-care clinicians are ideally suited to incorporate palliative care into their practice; and provide guidance to primary-care clinicians regarding how and when to access palliative-care specialist services, how to gain more training in palliative care, and how to be reimbursed for palliative-care visits.

The Voice of Surrogate Decision-Makers. Family Responses to Prognostic Information in Chronic Critical Illness

Rationale: Information from clinicians about the expected course of the patients illness is relevant and important for decision‐making by surrogates for chronically critically ill patients on mechanical ventilation. Objectives: To observe how surrogates of chronically critically ill patients respond to information about prognosis from palliative care clinicians. Methods: This was a qualitative analysis of a consecutive sample of audio‐recorded meetings from a larger, multisite, randomized trial of structured informational and supportive meetings led by a palliative care physician and nurse practitioner for surrogates of patients in medical intensive care units with chronic critical illness (i.e., adults mechanically ventilated for ≥7 days and expected to remain ventilated and survive for ≥72 h). Measurements and Main Results: A total of 66 audio‐recorded meetings involving 51 intervention group surrogates for 43 patients were analyzed using grounded theory. Six main categories of surrogate responses to prognostic information were identified: (1) receptivity, (2) deflection/rejection, (3) emotion, (4) characterization of patient, (5) consideration of surrogate role, and (6) mobilization of support. Surrogates responded in multiple and even antithetical ways, within and across meetings. Conclusions: Prognostic disclosure by skilled clinician communicators evokes a repertoire of responses from surrogates for the chronically critically ill. Recognition of these response patterns may help all clinicians better communicate their support to patients and families facing chronic critical illness and inform interventions to support surrogate decision‐makers in intensive care units. Clinical trial registered with www.clinicaltrials.gov (NCT 01230099).

Data-driven interdisciplinary interventions to improve inpatient pain management.

Pain during hospitalization and dissatisfaction with pain management are common. This project consisted of 4 phases: identifying a pain numeric rating scale (NRS) metric associated with patient satisfaction, identifying independent predictors of maximum NRS, implementing interventions, and evaluating trends in NRS and satisfaction. Maximum NRS was inversely associated with favorable pain satisfaction for both efficacy (n = 4062, χ2 = 66.2, P < .001) and staff efforts (n = 4067, χ2 = 30.3, P < .001). Independent predictors of moderate-to-severe maximum NRS were younger age, female sex, longer hospital stay, admitting department, psychoactive medications, and 10 diagnostic codes. After interventions, moderate-to-severe maximum NRS declined by 3.6% per quarter in 2010 compared with 2009. Satisfaction data demonstrated improvements in nursing units meeting goals (5.3% per quarter, r2 = 0.67) and favorable satisfaction answers (0.36% per quarter, r2 = 0.31). Moderate-to-severe maximum NRS was an independent predictor of lower likelihood of hospital discharge (likelihood ratio = 0.62; 95% confidence interval = 0.61-0.64). Targeted interventions were associated with improved inpatient pain management.

Building a Supportive Oncology Practice that Impacts Emergency Department Visits, Hospice Utilization, and Hospital Admission

INTRODUCTION Palliative care remains underutilized despite evidence supporting its value. Multiple professional organizations have endorsed broader and earlier access to palliative care, yet barriers exist that impede successful implementation of palliative care. We report on development of an ambulatory palliative medicine practice (Supportive Oncology) embedded within an academic cancer center. METHODS An incremental strategy was used to ensure the sustainability of the practice. A needs assessment of oncologists gauged perceptions of unmet patient needs, attitudes toward palliative care, reasons for referrals, and vision of a relationship with palliative care. Clinical outcomes included practice volume, healthcare utilization, and hospice enrollment. RESULTS Key themes identified included diverse palliative care needs, variable reasons for referral, and lack of consensus on palliative cares role as a consultant or comanagement model. Supportive oncology visits were associated with a 12% reduction in emergency department visits and a 39% decrease in the cost of each visit. Percentage of hospice enrollment 30 days before death exceeded the national average, and was twice the local average. CONCLUSION Providing ambulatory palliative care simultaneously with disease-directed oncologic care improves healthcare value. Despite regional variations in hospital culture and patient populations, the model described here can be adapted in a variety of settings. More research is needed to identify the optimal model of ambulatory palliative care delivery, including type and structure of integration, needs of patients, and level of generalist-level palliative care provided by oncologists.

Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department

Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.

Speech-Language Pathologist

RESPONSIBILITIES: Under the direction of the Superintendent of Educational Services, the Speech Language Pathologist will take a lead role throughout our Board to enhance the communication, social and educational functions of students with speech and language disorders and augmentative/alternative communication needs by providing on-going screening, assessment, consultation and training. In addition, they will provide program supervision and guidance to Communication Disorder Facilitators, assist in pertinent Board/department planning and liaison with internal and external partners.

Prevention and Chemoprophylaxis in the Elderly

Upon completion of the chapter, the student will be able to: 1. Identify the important factors involved in deciding whether primary or secondary prevention interventions should be applied to a specific disease process. 2. Recognize screening guidelines that are important to the geriatrics population. 3. Provide age-appropriate preventive recommendations and lifestyle counseling.