Gary T. Buckholz

Nonpharmacological management of dyspnea

Purpose of reviewDyspnea is a common symptom experienced by patients suffering from life-limiting illnesses. This review aims to summarize the nonpharmacological therapies that exist to treat this complex symptom. Recent findingsThere is a wide array of nonpharmacological therapies to target the symptom of dyspnea by either changing physiologic factors or modifying the subsequent emotional response associated with the experience. Current research has been geared primarily toward patients with chronic obstructive pulmonary disease. Research related to other life-limiting illnesses and mind–body approach is starting to emerge. Invasive or noninvasive ventilation can be considered for some progressive illnesses when the symptom is refractory to other therapies. SummaryNonpharmacological therapies to treat the symptom of dyspnea are abundant. These therapies may be considered first-line as many have a low risk profile and allow for an integrative approach while avoiding polypharmacy. More research is needed to determine the degree of potential benefit we can anticipate from these therapies.

Clinical utility of naloxegol in the treatment of opioid-induced constipation

Opioids are a class of medications frequently used for the treatment of acute and chronic pain, exerting their desired effects at central opioid receptors. Agonism at peripherally located opioid receptors, however, leads to opioid-induced constipation (OIC), one of the most frequent and debilitating side effects of prolonged opioid use. Insufficient relief of OIC with lifestyle modification and traditional laxative treatments may lead to decreased compliance with opioid regimens and undertreated pain. Peripherally acting mu-opioid receptor antagonists (PAMORAs) offer the reversal of OIC without loss of central pain relief. Until recently, PAMORAs were restricted to subcutaneous route or to narrow patient populations. Naloxegol is the first orally dosed PAMORA indicated for the treatment of OIC in noncancer patients. Studies have suggested its efficacy in patients failing traditional constipation treatments; however, insufficient evidence exists to establish its role in primary prevention of OIC at this time.

Advance Care Planning and Palliative Care Integration for Patients Undergoing Hematopoietic Stem-Cell Transplantation

PURPOSE Advance care planning (ACP) in hematopoietic stem-cell transplantation (HSCT) is challenging, given the potential for cure despite increased morbidity and mortality risk.The aim of this study was to evaluate ACP and palliative care (PC) integration for patients who underwent HSCT. METHODS A retrospective analysis was conducted and data were extracted from electronic medical records of patients who underwent HSCT between January 2011 and December 2015. Patients who received more than one transplant and who were younger than 18 years of age were excluded. The primary objective was to determine the setting and specialty of the clinician who documented the initial and final code status. Secondary objectives included evaluation of advance directive and/or completion of the Physician Orders for Life-Sustaining Treatment form, PC consultation, hospice enrollment, and location of death. RESULTS The study sample comprised 39% (n = 235) allogeneic and 61% (n = 367) autologous HSCTs. All patients except one (n = 601) had code status documentation, and 99.2% (n = 596) were initially documented as full code. Initial and final code status documentation in the outpatient setting was 3% (n = 17) and 24% (n = 143), respectively. PC consultation occurred for 19% (n = 114) of HSCT patients, with 83% (n = 95) occurring in the hospital. Allogeneic transplant type and age were significantly associated with greater rates of advance directive and/or Physician Orders for Life-Sustaining Treatment completion. Most patients (85%, n = 99) died in the hospital, and few were enrolled in hospice (15%, n = 17). CONCLUSION To our knowledge, this is the largest single-center study of ACP and PC integration for patients who underwent HSCT. Code status documentation in the outpatient setting was low, as well as utilization of PC and hospice services.

Advance care planning and palliative care consultation for stem cell transplant patients.

113 Background: Advance care planning (ACP) in stem cell transplantation (SCT) is particularly challenging given the potential for cure for patients with blood cancers despite an increased risk of suffering and even death. Data regarding ACP and palliative care (PC) integration in SCT is limited. METHODS A retrospective chart review was conducted of patients with hematologic malignancies who underwent SCT at UCSD from January 2011 to December 2015. The primary objective was to determine the medical discipline of the initial and last code status documentation. Secondary objectives included evaluation of AD and/or POLST completion, PC consultation, hospice enrollment, and location of death. Data were compiled from a single electronic medical record and descriptive statistical analyses performed. RESULTS A total of 633 SCT were performed from 2011 to 2015 including 39% (n = 245) allogeneic and 61% (n = 388) autologous transplants (n = 29 patients had 2 transplants). Mean age of SCT patients was 55 years (±13). All but one (n = 632) had code status documentation, and 0.8% (n = 5) were initially DNR. The initial code status was documented outpatient for 3% (n = 17), and by the primary SCT physician for 1 patient. The final code status was documented outpatient for 22% (n = 14), and by the primary SCT physician for 0.9% (n = 6). Nearly half (44%, n = 279) had an AD and/or POLST completed. PC consultation occurred for 19% (n = 121) with the majority (83%, n = 101) completed inpatient. PC consultation requests were made by the primary SCT physician (18%, n = 22), inpatient SCT team (68%, n = 82), critical care (8%, n = 10), or other (5%, n = 6).The most common reason for consultation was symptom management (80%, n = 94). As of January 2016, 20% (n = 127) of SCT patients died with a mean time from transplant of 312 days (± 317). Of those that died, the majority (83%, n = 106) died in the hospital, 15% (n = 19) were full code, 48% (n = 62) had an AD and/or POLST, and 14% (n = 18) were enrolled in hospice. CONCLUSIONS These single center data suggest ACP and PC integration in SCT is limited. Opportunities exist to expand integration to the outpatient setting and earlier in the course of illness.

Blood transfusions at end of life for stem cell transplant patients.

115 Background: Transfusions are an essential palliative tool in the stem cell transplant (SCT) population. Limited data exist regarding transfusion practices at end-of-life for SCT patients and whether these practices may limit enrollment in hospice. METHODS A retrospective chart review was conducted of deceased patients with hematologic malignancies who underwent SCT at an academic medical center from 2011 to 2015. The primary objective was to determine the difference between the dates of last transfusion and death in patients enrolled and not enrolled in hospice. A secondary objective was evaluation of the number of transfusions between groups. Data were compiled from a single electronic medical record. Descriptive analyses were performed. Days to last transfusion were analyzed using the Wilcoxon-Mann-Whitney test. Number of packed red blood cell (PRBC) transfusions and platelets transfusions on the last day were analyzed using Fisher and chi-squared tests, respectively. RESULTS A total of 633 SCT were performed from 2011 to 2015 including 39% (n = 245) allogeneic and 61% (n = 388) autologous transplants (n = 29 patients had 2 transplants). Mean ± SD age of SCT patients was 55 ± 13 years. As of January 2016, 20% (n = 119) of these SCT patients have died. Of those that died, 15% (n = 18) were enrolled in hospice. For SCT patients enrolled in hospice, the mean ± SD time of last blood transfusion from death was 42.3 ± 63.4 days, with mean ± SD 0.67 ± 0.77 units of PRBCs and 0.72 ± 0.75 units of platelets administered. For SCT patients not enrolled in hospice, the mean ± SD time of last blood transfusion from death was 14.2 ± 47.9 days, with mean±SD total 0.69 ± 1.03 units of PRBCs and 1.14 ± 1 units of platelets administered. Hospice patients had a statistically significant longer number of days until last blood transfusion compared to non-hospice patients (p < 0.001). There was no difference between SCT patients enrolled in hospice and not enrolled in PRBC transfusions (p = 0.069), but there was a significantly higher amount of platelet transfusions in patients not enrolled in hospice (p < 0.005). CONCLUSIONS This data suggests that time to last transfusion may be a significant obstacle for SCT patients when enrolling in hospice, but requires further validation.

Fellowship Directors’ Program—What Keeps us Awake at Night: Addressing the Challenges of Palliative Medicine Fellowship Programs as the Next Accreditation System and the Match Become Reality (P04)

Ignite your leadership potential. Financial DecisionMaking Approaches is designed to equip hospice and palliative medicine physicians with foundational principles in financial management to increase their understanding of institutional or organizational financial reports. This course will provide an introduction to financial concepts and terminology followed by an exploration of cost analysis and resource allocation using sample financial tools and documents, case studies, and scenarios to provide practical relevance for HPM physicians. This preconference program is offered in partnership with the American Association for Physician Leadership (Association) and presented by Association faculty. This session applies to all physician leaders and practice settings looking to enhance their financial management understanding and decision-making for their organization. Primary leadership competencies addressed in this program include financial acumen and resource management. AAHPM Ignite is one of three sessions included in the AAHPM Leadership Forum. AAHPM and the American Association for Physician Leadership have designed a comprehensive leadership training program that offers a variety of learning opportunities and varied environments, including face-to-face didactic instruction and Web-based self-study. You can create your own customized and flexible learning pathway and select content based on your unique leadership development goals and career pathway. Learn more at aahpm.org/career/leadership.

Add Your Voice: Vetting the Entrustable Professional Activities for HPM Physicians (TH335)

1994 to 2003, the PDIA created funding initiatives in professional and public education, the arts, research, clinical care, and public policy that transformed care for patients living with serious illnesses in the United States. Four PDIA Awards will be presented: the AAHPM PDIA Palliative Medicine National Leadership Award, the AAHPM PDIA Palliative Medicine Community Leadership Award, the HPNF PDIA Nursing Leadership Award in Palliative Care, and the SWPHN PDIA Career Achievement Award. Award recipients will participate in panel presentations on topics such as career trajectory, lessons learned, and take-away ‘‘pearls’’ for the attendees.

GI Palliative Care Issues

The physician should always consider the etiology and pathophysiology of constipation, nausea, and vomiting before starting treatment. The work up and treatment for the symptom of abdominal pain includes a digital rectal exam for complete assessment of constipation and diarrhea. A plain abdominal radiograph is an inexpensive and useful tool for this type of evaluation. Stimulant laxatives are the treatment of choice for opioid-induced constipation. Pain at the end of life is often treated with opioid analgesics which are consequently associated with GI issues. Opioids cause constipation for which tolerance does not occur and requires prophylaxis. Fiber or other bulk forming laxatives can worsen opioid-induced constipation. Additional symptoms or problems that might develop related to abdominal pain include pseudodiarrhea.