J. Cameron Muir

Palliative care and the hospitalist: an opportunity for cross-fertilization

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Palliative care at the end of life: Comparing quality in diverse settings

There is growing awareness that pain and other symptoms are often poorly managed at the end of life. The purpose of this quality improvement project was to compare the quality of care provided to a convenience sample of 195 patients who died during a six-month period, using a retrospective chart review. Quality was defined by symptom documentation, use of diagnostic and therapeutic procedures in the final 48 hours of life, and determination of advance directives. Daily and total charges incurred by these patients were also captured. Symptom distress was common, and diagnostic and therapeutic procedures were widespread. These data suggest areas for improvement in clinical practice, in palliative care units, and in all settings where end-of-life care is provided. Also, the data can guide future research into the quality of care provided to dying persons.

Antisecretory agents in gastrointestinal obstruction.

Gastrointestinal obstruction is associated with nausea, vomiting, and abdominal pain. Antisecretory agents can relieve these symptoms, even in the absence of surgical or mechanical intervention. These medical management approaches are outlined, and recommendations are made.

Alternative Routes to Oral Opioid Administration in Palliative Care: A Review and Clinical Summary

OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.

Developing an Ethics Curriculum for an Internal Medicine Residency Program: Use of a Needs Assessment

Background: Residency programs are required to teach and evaluate trainees in the area of professionalism and medical ethics. Prior to developing a curriculum in this area, residents and fellows were surveyed to assess learning needs. Description: A case-based survey was developed based on published curricula. Residents and fellows were asked to describe their comfort level in 11 clinical scenarios on a Likert-type scale ranging from 1 (not at all comfortable) to 10 (extremely comfortable). Evaluation: 151 surveys were returned for an overall response rate of 73%. Comfort levels ranged from a low of 3.1 to a high of 8.5 on the 10-point scale. Despite additional years of clinical training, fellows only reported an increased comfort level in 1 case. Conclusion: Learning needs exist in residents and fellows in the area of medical ethics. Use of a needs assessment was instrumental in planning and designing an ethics curriculum.

Not ready for hospice: characteristics of patients in a pre-hospice program.

Context: There are many patients with terminal illness for whom hospice care would be appropriate, but they either never enroll or enroll very late. In a pre-hospice program designed to help patients make the transition into hospice, we observed that many patients did not make the transition. Objectives: To understand more about the transition to hospice and the functions of a pre-hospice program, this paper compares patients who enrolled in hospice with those who died in the pre-hospice program. Design, setting, and patients: Data were collected from a retrospective review of the charts of 123 consecutive patients who enrolled in a prehospice program between January 1, 1995, and December 31, 1996. Main outcome measures: The patient’s decision to transfer to home hospice or (perhaps, by not making a decision) to remain enrolled in the pre-hospice program until death. Results: At the end of the research period, 38 patients had transferred to hospice and 36 had died without transfer. The remaining 49 patients had uncertain outcomes at the end of the research period. Patients who transferred to hospice were older (P = .02) and more likely to have secondary insurance (P = .05). In addition, those who enrolled in hospice were more likely to live alone (P = .03) and have psychosocial concerns noted by staff on admission (P = .05). Conclusions: Many patients died in this program that was designed only for transition to hospice. We found statistically significant differences characterizing the groups associated with transferring to hospice. Further studies to find out why these differences exist will be important in order to provide excellent end-of-life care for more people.

Palliative medicine: an emerging field of specialization.

The prevailing model of medical care for patients with cancer emphasizes the curative efforts of medical technology toward the eradication of the disease. Yet the suffering of the patient as a result of both the disease and efforts to treat it is often overlooked. Although the only way to improve the survival of patients with cancer is through intensive research into the molecular underpinnings of the disease, it is essential to recognize and concomitantly address the suffering of cancer patients. The relief of suffering as a goal of medical therapy and an object of professional expertise is the focus of a growing number of healthcare providers. Physicians who focus on the relief of suffering are referred to as specialists in “palliative medicine.” In this article we describe the development of the field of palliative medicine as a legitimate area of physician specialization and place the field in the context of the spectrum of care of patients with cancer. It should be noted, however, that the field is developing for the care of all patients with

Abdominal cancer, nausea, and vomiting.

Nausea and vomiting in abdominal cancer is perhaps one of the most difficult symptom complexes to manage, especially when complicated by bowel obstruction. There are many mechanisms of nausea in advanced abdominal cancer with a number of therapeutic interventions that can significantly enhance symptom control and overall quality of life. As with pain, the ideal approach should include a mechanistic analysis of the causes of nausea beginning with a thorough history, followed by a directed physical examination, and selected laboratory studies. The symptom history, in conjunction with a physical examination and directed tests should direct appropriate pharmacologic and nonpharmacologic interventions. The result is often the amelioration of significant suffering and enhanced quality of living.

Opioid Prescribing Practices Before and After Initiation of Palliative Care in Outpatients

CONTEXT Prescription Monitoring Programs (PMPs) are being developed and implemented in many states to deter abuse, diversion, and overdose, and physicians may use PMPs to help guide their treatment choices for individual patients. OBJECTIVES To evaluate the changes in prescribing practices and pain score outcomes in patients with cancer before and after an initial consult in an outpatient palliative care clinic. METHODS This is a retrospective study with a sample of 60 consecutive patients who had been referred by oncologists for difficult-to-manage pain and whose initial palliative care consult was with either of the two physicians in the outpatient palliative care clinic. For each patient, lists were compiled of all prescriptions for controlled medications and filled for the 90-day periods immediately before and after the initial consult. Data from patient charts were combined with information from the Virginia PMP, which included prescriptions written before and after the initiation of palliative care, written by prescribers both inside and outside the palliative care clinic. RESULTS After the palliative care consult, the proportion of patients on long-acting opioids increased from 45% to 73%. Self-reported pain outcomes, which were compiled for the subset of patients who continued palliative care for at least 60 days, showed a median decrease of two units on a 0-10 scale. A decrease was seen in the use of medications that compound acetaminophen with opioids. CONCLUSION Data from a PMP proved useful in understanding the changes in a population of patients. Favorable changes were observed in prescribing practices and pain outcomes.

Palliative care and the hospitalist: an opportunity for cross-fertilization.

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.