Sarah E. Harrington

The Role of Chemotherapy at the End of Life: "When Is Enough, Enough?"

Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed.

Development of a Comprehensive E-Learning Resource in Pain Management

OBJECTIVE The prevalence of chronic nonmalignant pain (CNMP), the lack of confidence and reward among trainees and providers caring for patients with CNMP, and the lack of a comprehensive curriculum in pain management prompted the creation of the Virginia Commonwealth University (VCU) Chronic Nonmalignant Pain Management curriculum, an innovative e-learning resource. This article describes the development of the curriculum and presents initial evaluation data. DESIGN The curriculum is organized into six modules that cover 20 specific Accreditation Council of Graduate Medical Education competency-based objectives. Broad content and effective instructional design elements promote its utility among a range of learner levels in a variety of medical disciplines. RESULTS Twenty-four physician reviewers and over 430 trainees (medical students and graduate medical residents) have evaluated the curriculum. Of the respondents to course evaluation questions, 85.7% (366/427) stated that they would access the practice resources again, 86.3% (366/424) agreed that the treatment of CNMP was more important to them after completing the curriculum, 73.9% (312/422) stated that they would make changes in their behavior or practice, and 92.3% (386/418) stated that they would recommend the curriculum to their colleagues. Qualitative data are uniformly positive. Results of pretest and posttest scores and item analyses have been used to make content changes. CONCLUSIONS The VCU Chronic Nonmalignant Pain Management curriculum is an e-learning resource that has the potential to fill a significant training void. Design and content changes have been made as a result of initial evaluation data. Data from ongoing evaluation will allow curricular refinement.

Managing Pain with Algorithms: An Opportunity for Improvement? Or: The Development and Utilization of Algorithms to Manage Acute Pain

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committees efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

Palliative care and chronic obstructive pulmonary disease: where the lines meet.

Purpose of review Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and is expected to increase as the population ages. Patients have a high symptom burden, low healthcare quality of life, and unmet needs at the end of life. This review highlights specific palliative care needs of patients with advanced COPD and opportunities to integrate palliative care into standard practice. Recent findings There are many barriers to providing integrated palliative care in COPD, including difficulty with prognostication, communication barriers surrounding advance care planning, and lack of access to specialty palliative care. Because of the unique disease trajectory, emphases on early and primary palliative care are being studied in this patient population. Summary Palliative care is appropriate for patients with COPD and should be integrated with disease-specific therapies. The line between life prolonging and palliative care undoubtedly overlaps and maximizing quality of life throughout the continuum of care should be prioritized for patients with this progressive illness.

Cancer patient perspectives regarding preparedness for end-of-life care: A qualitative study

ABSTRACT Purpose: The extent to which patients feel prepared for end-of-life (EOL) may be associated with important clinical outcomes. Despite growing interest in the concept of “preparedness,” however, there is insufficient information about what cancer patients actually need to feel prepared. Such information is foundational for patient-centered care, theory-building, and instrument development. Design: This qualitative study examined patient perspectives regarding preparedness for EOL care. Participants and methods: In-depth interviews were conducted with patients with advanced malignancies and limited life expectancies. Participants were drawn from a large academic cancer center and had a diverse range of malignancies. Thematic text analysis was used to analyze the data. Findings: Six overarching themes emerged. These included readiness to manage concerns about: (1) EOL planning (e.g., goals of care, location of care); (2) interactions with healthcare providers (e.g., communication, symptom control); (3) interactions with family/friends (e.g., perceived burden, support); (4) emotional well-being (e.g., existential distress, fulfillment); (5) spiritual well-being (e.g., spiritual comfort, congregational support); and (6) financial well-being (e.g., medical expenses, estate planning). Conclusions: Findings highlight areas that patients themselves regard as critical for a sense of preparedness for EOL care. Participants emphasized broader concerns than those previously construed as facets of patient preparedness, and these domains offer modifiable targets for intervention.

Caregiver: Roles in Health Management

Overview: As the number of caregivers increase in America, it is important for providers to understand the unique ethnic and cultural characteristics and needs of caregivers in order to provide the highest quality care for our aging patients. This chapter is focused primarily on the unpaid informal caregiver.

Adherence to Adjuvant Neuropathic Pain Medications in a Palliative Care Clinic.

Abstract Background: Currently, few studies exist on patient adherence to adjuvant neuropathic pain medications in the palliative care setting. Objectives: We assessed patient adherence rates to neuropathic pain medications in a palliative care clinic and compared patient self-reported adherence to pharmacy refill records. Methods: This was an observational single site cross-sectional study of patients with neuropathic pain receiving at least one neuropathic pain medication for at least three months. Participants who met the inclusion criteria and agreed to participate completed a 7-day-recall (7DR) adherence measure and gave permission to contact their pharmacy after the visit to collect refill records for the six months before the clinic visit. This information was used to calculate the medication possession ratio (MPR). Results: We analyzed 32 patients; most (81%) had neuropathic pain related to a cancer diagnosis. The mean self-reported adherence based on 7DR was 94%. The mean MPR was 63%. A majority ...BACKGROUND Currently, few studies exist on patient adherence to adjuvant neuropathic pain (NP) medications in the palliative care setting. OBJECTIVES We assessed patient adherence rates to NP medications in a palliative care clinic and compared patient self-reported adherence to pharmacy refill records. METHODS This was an observational single-site cross-sectional study of patients with NP receiving at least one NP medication for at least three months. Participants who met the inclusion criteria and agreed to participate completed the eight-item Morisky Medication Adherence Scale (MMAS-8) and a seven-day-recall (7DR) adherence measure. Patients gave permission to contact their pharmacy after the visit to collect refill records for the six months prior to the clinic visit. This information was used to calculate the medication possession ratio (MPR). RESULTS We analyzed 32 patients; most (81%) had NP related to a cancer diagnosis. Approximately 87.5% had low or medium adherence using the MMAS-8. The mean self-reported adherence based on 7DR was 94%. The mean MPR was 63%. A majority of patients (88%) had high self-reported adherence (>80%); however only 44% of patients had an MPR >80%. CONCLUSION Results indicated that the MPR might be a more accurate measure of adherence than patient self-report. More research is needed to assess and improve adherence with NP medications in the outpatient palliative care setting.

553: NATIONAL TRENDS (2009-2013) FOR PALLIATIVE CARE UTILIZATION IN MECHANICALLY VENTILATED PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) Specifically, to measure FMs’ symptoms of anxiety, depression, posttraumatic stress (PTSD), prolonged grief, and satisfaction with ICU care as compared to ICU FMs who did not receive bereavement follow-up. Methods: This cross-sectional, prospective pilot study assessed 40 FMs in two tertiary care ICUs. FMs of patients who died in the Medical-Surgical ICU (MS ICU) received bereavement follow up, and FMs of patients who died in the Cardiac ICU (CICU) did not receive bereavement follow up. FMs completed surveys 13 months after the ICU experience including: the HADS (anxiety and depression), IES-R (posttraumatic stress), PG-13 (prolonged grief ), and the FS-ICU (family satisfaction with ICU care). Aims were analyzed using student’s t-test, ANCOVA, and Chi-square. Results: There were 30 FMs in the bereavement group and 10 FMs in the non-bereavement group. Most were female (n = 29, 72.5%), spouses (n = 29, 72.5%), white (n = 31, 77.5%), with a mean age (SD) of 60.1 (13.3). Non-bereavement FMs group had statistically significant more prolonged grief than bereavement group FMs (p = 0.012). There were no significant differences between the two groups in PTSD, anxiety, depression, or ICU satisfaction. However, the overall scores for PTSD and anxiety were trending higher for the non-bereavement group than the bereavement group (mean of PTSD 1.5, vs 1.2; mean of anxiety 7.4 vs 5.9), where a mean score of 1.5 on the IES-R indicates a significant risk of PTSD. Conclusions: Study findings suggest that bereavement follow-up after an ICU death may help reduce family members’ prolonged grief. This type of support may also reduce FMs’ levels of PTSD and anxiety, although it did not have a measurable effect on depression or satisfaction with ICU care.