Eva Chittenden

Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v -3.40; P = .010) but not week 12 (0.39 v -1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, -1.17; 95% CI, -2.33 to -0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

Purpose Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. Method Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. Results The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. Conclusions This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

Integration of Palliative Care in End-Stage Liver Disease and Liver Transplantation

BACKGROUND Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community. DISCUSSION This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care. CONCLUSION Tremendous opportunity exists to integrate palliative medicine into the care of these patients.

Transitional clerkship: an experiential course based on workplace learning theory.

Starting clerkships is anxiety provoking for medical students. To ease the transition from preclerkship to clerkship curricula, schools offer classroom-based courses which may not be the best model for preparing learners. Drawing from workplace learning theory, the authors developed a seven-day transitional clerkship (TC) in 2007 at the University of California, San Francisco School of Medicine in which students spent half of the course in the hospital, learning routines and logistics of the wards along with their roles and responsibilities as members of ward teams. Twice, they admitted and followed a patient into the next day as part of a shadow team that had no patient-care responsibilities. Dedicated preceptors gave feedback on oral presentations and patient write-ups. Satisfaction with the TC was higher than with the previous years classroom-based course. TC students felt clearer about their roles and more confident in their abilities as third-year students compared with previous students. TC students continued to rate the transitional course highly after their first clinical rotation. Preceptors were enthusiastic about the course and expressed willingness to commit to future TC preceptorships. The transitional course models an approach to translating workplace learning theory into practice and demonstrates improved satisfaction, better understanding of roles, and increased confidence among new third-year students.

Screening immigrants and international travelers for the human immunodeficiency virus

Global strategies to control infectious disease have historically included the erection of barriers to international travel and immigration.1 2 3 Keeping people with infectious diseases outside nat...

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

Objective: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. Background: During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. Methods: We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. Results: We recorded 43 patients’ conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. Conclusions: Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial

This article reports a single‐center randomized clinical trial that evaluated the effect of early integrated specialty palliative care on patient‐ and caregiver‐reported outcomes in patients with newly‐diagnosed, incurable cancers. It was hypothesized that caregivers of patients assigned to early integrated palliative care would report lower psychological distress and better quality of life compared with caregivers of patients assigned to usual oncology care.

A faculty development workshop in teaching reflection

of the seven modules had been completed, a number of regional, national and international experts in medical education validated the diploma curriculum. The Medical Sector of the Supreme Council of Universities has endorsed the diploma course and recognised its certificate as representative of the only formal course in medical education in Egypt that is taught through distance learning. The 5-year goal of the programme is to train 5% of HPE faculty across the country. The diploma curriculum is designed to ensure that the alumni of this programme will educate other educators in their institutions and make a real impact on HPE in Egypt.

Skin Findings in Palliative Care Patients

The prevalence of dermatologic disease and its effect on quality of life has not been well studied in patients with advanced illness. We sought to describe skin findings in inpatient palliative care patients and determine how often they are addressed by the primary or palliative care teams. We collected patient demographic and clinical data from the medical record, performed total body skin examinations, and determined how often significant cutaneous findings were documented in the chart. We also characterized skin findings as uncomfortable and treatable. Twenty palliative care patients participated in the study over a 2-month period. Common findings included skin breakdown (20/54; 37%), skin infections (14/54; 26%), inflammatory dermatoses (9/54; 17%), and skin conditions related to systemic disease (7/54; 13%) or treatment of systemic disease (4/54; 7%). Most of these conditions were not documented by primary or palliative care clinicians. Eighty percent of the patients had uncomfortable, but treatable skin conditions of which 62% (13/21) were undocumented or incorrectly documented. These limited data suggest the need for palliative care clinicians to conduct more complete skin examinations, and to improve their knowledge of common skin abnormalities in patients with serious illness. A larger scale investigation of skin disease and its effect on quality of life in the palliative care population is warranted.

An Evaluation of Interactive Web-Based Curricula for Teaching Code Status Discussions

BACKGROUND Teaching resuscitation discussions to medical students and residents is time intensive and should be taught by teachers with competence in this area of clinical practice. There are plenty of data that these discussions are often inadequate, and that communication skills training, while time and faculty intensive, improves these conversations. The role of online instruction in teaching communication skills, such as resuscitation discussions, is not established. OBJECTIVE The study objective was to evaluate the effectiveness of an interactive online curriculum in teaching code status discussions to third-year medical students at one medical school. DESIGN In this study we block randomized third-year medical students to one of two web-based curricula versus a similar written curriculum and used standardized patient scores on a communication exercise to measure differences in performance. We used student surveys to measure student satisfaction with the curricula. SETTING/SUBJECTS Of 121 students participating in the study between April 2007 and March 2008, 88 were randomized to one of two website formats and 33 to the written curriculum. MEASUREMENTS We compared average scores on content and communication checklists between groups. RESULTS There were no differences between the three groups in the primary outcome of student performance. We could not analyze data on satisfaction with or completion rates for the three curricula due to poor response rates to the student surveys. CONCLUSIONS This block randomized study of web-based curricula versus a written curriculum did not show differences in student performance in code status discussions. The optimal use of online communication training remains unclear and requires further investigation.