Molly A. Feely

A survey of clinician attitudes and self-reported practices regarding end-of-life care in heart failure

Background: As heart failure often follows an unpredictable clinical trajectory, there has been an impetus to promote iterative patient-provider discussions regarding prognosis and preferences for end-of-life care. Aim: To examine clinicians’ practices, expectations, and personal level of confidence in discussing goals of care and providing end-of-life care to their patients with heart failure. Design: Multi-site clinician survey. Setting and Participants: Physicians, nurse practitioners, and physician assistants at Mayo Clinic (Rochester, Minnesota, USA) and its surrounding health system were asked to participate in an electronic survey in October 2013. Tertiary Care Cardiology, Community Cardiology, and Primary Care clinicians were surveyed. Results: A total of 95 clinicians participated (52.5% response rate). Only 12% of clinicians reported having annual end-of-life discussions as advocated by the American Heart Association. In total, 52% of clinicians hesitated to discuss end-of-life care citing provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness, fear of destroying hope (9%), or lack of time (8%). Tertiary and Community Cardiology clinicians (66%) attributed responsibility for end-of-life discussions to the heart failure cardiologist, while 66% of Primary Care clinicians felt it was their responsibility. Overall, 30% of clinicians reported a low or very low level of confidence in one or more of the following: initiating prognosis or end-of-life discussions, enrolling patients in hospice, or providing end-of-life care. Most clinicians expressed interest in further skills acquisition. Conclusion: Clinicians vary in their views and approaches to end-of-life discussions and care. Some lack confidence and most are interested in further skills acquisition.

Preparedness Planning Before Mechanical Circulatory Support: A “How-To” Guide for Palliative Medicine Clinicians

The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning.

Safety of Clopidogrel in Hip Fracture Surgery

OBJECTIVE To compare postoperative outcomes of hip fracture surgery in patients who were and were not taking clopidogrel at the time of surgery. PATIENTS AND METHODS Using the Rochester Epidemiology Project database, we performed a population-based, retrospective cohort study comparing patients who were and were not taking clopidogrel at the time of hip fracture surgery between January 1, 1996, and June 30, 2010. Primary outcomes were perioperative bleeding and mortality. Secondary outcomes were perioperative thrombotic events. RESULTS During the study period, 40 residents of Olmsted County, Minnesota (median age, 83 years), who were taking clopidogrel underwent hip fracture repair. These 40 patients were matched 2:1 with 80 control patients (median age, 84 years). The groups were similar in age, sex, American Society of Anesthesiologists score, type of surgical procedure, and use of deep venous thrombosis prophylaxis. The mean time from admission to surgery was less than 36 hours for each cohort. Perioperative bleeding complications and mortality were not significantly different between patients who were and were not taking clopidogrel at the time of hip fracture surgery. Combined bleeding outcome criteria was met in 48% of the clopidogrel cohort and 45% of the control cohort (relative risk, 1.06; 95% CI, 0.70-1.58; P=.80). One-year mortality was 28% in the clopidogrel cohort and 29% in the control cohort (hazard ratio, 1.33; 95% CI, 0.84-2.12; P=.23). CONCLUSION Although the small sample size precludes making a definitive conclusion, we found no evidence that prompt surgical treatment of hip fracture in patients taking clopidogrel compromises perioperative outcomes.

Prevalence and Contents of Advance Directives of Patients with ESRD Receiving Dialysis

BACKGROUND AND OBJECTIVES ESRD requiring dialysis is associated with increased morbidity and mortality rates, including increased rates of cognitive impairment, compared with the general population. About one quarter of patients receiving dialysis choose to discontinue dialysis at the end of life. Advance directives are intended to give providers and surrogates instruction on managing medical decision making, including end of life situations. The prevalence of advance directives is low among patients receiving dialysis. Little is known about the contents of advance directives among these patients with advance directives. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We retrospectively reviewed the medical records of all patients receiving maintenance in-center hemodialysis at a tertiary academic medical center between January 1, 2007 and January 1, 2012. We collected demographic data, the prevalence of advance directives, and a content analysis of these advance directives. We specifically examined the advance directives for instructions on management of interventions at end of life, including dialysis. RESULTS Among 808 patients (mean age of 68.6 years old; men =61.2%), 49% had advance directives, of which only 10.6% mentioned dialysis and only 3% specifically addressed dialysis management at end of life. Patients who had advance directives were more likely to be older (74.5 versus 65.4 years old; P<0.001) and have died during the study period (64.4% versus 46.6%; P<0.001) than patients who did not have advance directives. Notably, for patients receiving dialysis who had advance directives, more of the advance directives addressed cardiopulmonary resuscitation (44.2%), mechanical ventilation (37.1%), artificial nutrition and hydration (34.3%), and pain management (43.4%) than dialysis (10.6%). CONCLUSIONS Although one-half of the patients receiving dialysis in our study had advance directives, end of life management of dialysis was rarely addressed. Future research should focus on improving discernment and documentation of end of life values, goals, and preferences, such as dialysis-specific advance directives, among these patients.

Ethical challenges with hemodialysis patients who lack decision-making capacity: behavioral issues, surrogate decision-makers, and end-of-life situations

Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.

Management of End-of-Life Care and of Difficult Behaviors Associated With Borderline Personality Disorder

Psychologicalsufferingisoneofthemostdis-concertingissuesthatpatientsandfamiliesmayexperience attheendoflife(EOL). Inthefaceof a terminal illness, it is natural for patients tofeelgrief,sadness,despair,anger,pain,andanx-iety. Many are able to achieve acceptance, com-fort, and coping through the dying process.However,thedyingprocesscanbecomplicatedfor those with preexisting psychiatric disordersthat make them more vulnerable to distressandmayamplifytheirpsychological,emotional,physical, and spiritual suffering.Caring for patients with psychiatric and per-sonality disorders at the EOL is complex, giventhe nature of psychopathology and its impacton interactions between the patients and theproviders. We present a case of a patient witha terminal illness and comorbid borderlinepersonality disorder (BPD) and discuss man-agement challenges from palliative and psychi-atric perspectives.

End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy

BACKGROUND AND OBJECTIVES Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization. RESULTS Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4-11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P=0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P<0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P<0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P=0.02). CONCLUSIONS In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

Palliative Sedation and What Constitutes Active Dying A Case of Severe Progressive Dystonia and Intractable Pain

We present the case of a 34-year-old woman with Klippel-Feil syndrome who developed progressive generalized dystonia of unclear etiology, resulting in intractable pain despite aggressive medical and surgical interventions. Ultimately, palliative sedation was required to relieve suffering. Herein, we describe ethical considerations including defining sedation, determining prognosis in the setting of an undefined neurodegenerative condition, and use of treatments that concurrently might prolong or alter end-of-life trajectory. We highlight pertinent literature and how it may be applied in challenging and unique clinical situations. Finally, we discuss the need for expert multidisciplinary involvement when implementing palliative sedation and illustrate that procedures and rules need to be interpreted to deliver optimal patient-centered plan of care.

A Systematic Approach to the Preoperative Medical Evaluation of Adults

Abstract The number, age, and medical complexity of patients undergoing elective noncardiac surgery is rising worldwide. Internists, family physicians, and midlevel providers asked to perform preoperative medical evaluations. However, lack of consensus has led to wide variation in practice in what is included and addressed in these evaluations, and the efficacy of these assessments has been debated. The intended purpose of the evaluation seems to be universally accepted as aiming to assess and identify risks associated with the patients comorbid medical conditions and the specific surgical procedure. The goal is to minimize those risks. Herein, we propose a systematic approach to the preoperative medical evaluation based on the best available evidence and expert opinion, with an emphasis on identifying all potentially pertinent patient-and surgery-specific risk factors.

A Novel Program to Promote Competency and Hospice and Palliative Medicine Board Certification

Dear Editor:Board certification in Hospice and Palliative Medicine(HPM) by the American Board of Medical Specialties (ABMS)will require the completion of a 12-month clinical fellowshipafter2012.Toaccommodateestablished,mid-careercliniciansdesiring HPM certification and to improve staffing and sup-port of our rapidly growing HPM practice, we developed anovel curriculum and training experience. The ABMS Lear-ners’Programatourinstitution(MayoClinic,Rochester,MN)hasprovidedstructuredclinicalanddidactictraininginHPMoutside of a formal fellowship. The major goals of the pro-gram are to lead to clinical competence and to HPM-boardeligibility.Five physicians from our institution (two general inter-nists, one geriatrician, one psychiatrist, and one hematolo-gist) were selected to participate based on interest andaptitude for HPM. Participants use 20% clinical effort over a2-year period (2010–2012) to meet ABMS ‘‘Practice PathwayA’’ requirements (Table 1). Funding for the program has beenprovided by a combination of institutional grants and de-partmental support from the respective divisions of eachlearner. Learners have participated in the full range of HPMclinical activities to meet the ABMS requirement for sub-specialty-level exposure (Table 1). Learners regularly attendweekly HPM Fellowship didactics and participated in astructured ‘‘Boot Camp’’ with 12 hours of intense HPM ed-ucation in fundamental content areas. Direct feedback withprogram coordinators has been provided semi-annually.Learning has been augmented with off-campus electives in-cluding nursing home experience, home hospice visits, andattendance at national meetings (i.e., American Academy ofHospice and Palliative Medicine [AAHPM] National Meet-ing, Harvard Medical School Program in Palliative CareEducation and Practice [PCEP]). In the first 6 months of theprogram, learners were precepted by board-certified HPMphysicians on approximately 100 new consultations and80 follow-up visits. After the first year, learners will per-form consults independently, with HPM-certified physiciansavailable as backup. Thus far, learners have qualitativelyreported improved confidence with end-of-life discussionsand ethical issues, familiarity with Medicare HospiceGuidelines, and improvement in pain and symptom man-agement skills.To our knowledge, curricular programs with focused di-dactic and clinical content delivered systematically havenot been reported to enhance HPM board passing rate or toTable 1. ABMS Learners’ Program at Mayo Clinic, Rochester, MNPractice pathway A requirements How requirements were met800 hours in subspecialty-level practice of hospice andpalliative medicine including:Palliative Care Consult Service (1-year supervised and 1-yearindependent with ‘‘backup’’)