Lara M. Skarf

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

Introduction: Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes. Areas covered: A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared. Expert opinion: Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Spiritual Needs and Spiritual Care for Veterans at End of Life and Their Families

Spiritual care is an important domain of palliative care programs across the country and in the Veterans Affairs (VA) Healthcare System specifically. This qualitative study assessed the spiritual needs, spiritual care received, and satisfaction with spiritual care of both Veterans at the end of life and their families. Seventeen Veterans and 9 family members participated. They expressed a wide range of spiritual needs, including a wish of Veterans to have a better understanding of traumatic events that occurred during their combat experience. Some Veterans reported military experience enhanced their spirituality. Generally, respondents reported satisfaction with VA spiritual care, but indicated that Veterans may benefit from greater access to VA chaplains and explicit discussion of the impact of their military experience on their spirituality.

Patient–Physician Boundaries in Palliative Care Training: A Case Study and Discussion

Abstract The subject of patient-physician boundaries has been most extensively explored in the psychiatric literature, but to date, little has been published about this concept within the realm of palliative care. Some palliative care physicians may be particularly susceptible to boundary crossings due to the intensity and intimacy of the bonds that form with patients at the end-of-life. We illustrate the concept of boundary crossings and violations in palliative care using the case of a palliative care trainee who experiences difficulties in maintaining boundaries with a dying patient. We discuss the nature of the patient-physician relationship using role theory and discuss how the formation of dual roles can be detrimental to the patient-physician relationship. Finally, we explore why palliative care practitioners and trainees are particularly vulnerable to crossing boundaries and how to recognize and manage these crossings when they occur.

P05.46. Spiritual needs of veterans: healthcare implications for returning troops

Purpose Spirituality plays an important role for many people. In particular, its crucial role among people at the end-oflife (EoL) has been recognized. Currently one out of 4 deaths in the US is a veteran. The study of spirituality among veterans who are at the EoL is therefore urgently needed. The objectives of this study are to understand the spiritual needs and spiritual care provided to veterans at the EoL in the Veteran Administration (VA) Healthcare System. We particularly focused on how military experience impacts spirituality and the spiritual care for veterans who, at the EoL, are still suffering from these experiences.

Improving Palliative Care Team Meetings: Structure, Inclusion, and "Team Care".

Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients’ plans of care, thus positively impacting team members’ ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting “toolkit.”

End-of-Life Care of Older Adults

Serious illness and end-of-life issues are challenging areas for clinicians caring for older adults. Patients may benefit from services offered by hospice, which cares for patients in the last 6 months of life, as well as palliative care, which offers an interdisciplinary approach focused on symptom management and supportive care for patients with serious illness of any time course. This chapter discusses indications for when it is appropriate to consider palliative care or hospice referrals for geriatric patients, as well as introducing prognostication tools available to guide these decisions and conversations. Some patients at the end of life may suffer from symptoms amenable to palliation, and others may decide to forgo or withdraw potentially life-prolonging treatments depending on their goals of care. The ethical challenge of requests for hastening death is discussed in addition to the ethical aspects of physician aid-in-dying legislation.