Sean O’Mahony

Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more “palliative care triggers” on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

Posttraumatic stress symptoms in palliative care professionals seeking mindfulness training: Prevalence and vulnerability

Background: Vicarious exposure to trauma is ubiquitous in palliative medicine. Repeated exposure to trauma may contribute to compassion fatigue and posttraumatic stress disorder symptoms in medical and supportive care professionals such as physicians, nurses, and social workers. These symptoms may be intensified among medical and supportive care professionals who use avoidant or rigid coping strategies. Aim: This study aimed to provide an estimate of posttraumatic stress disorder symptoms in a sample of professionals who work in palliative care settings, and have already been enrolled in mindfulness-based communication training. Design: Palliative care providers provided self-reported ratings of posttraumatic stress disorder symptoms, depression, and coping strategies using validated measures including the Acceptance and Action Questionnaire, Cognitive Fusion Questionnaire, and the Posttraumatic Stress Disorder Checklist–Civilian Version. Setting/participants: A total of 21 professionals working with palliative care patients completed assessments prior to beginning mindfulness-based communication training. Results: Posttraumatic stress disorder symptoms were prevalent in this sample of professionals; 42% indicated positive screens for significant posttraumatic stress disorder symptoms, and 33% indicated probable posttraumatic stress disorder diagnosis. Conclusion: Posttraumatic stress disorder symptoms may be common among professionals working in palliative medicine. Professionals prone to avoidant coping and those with more rigid negative thought processes may be at higher risk for posttraumatic stress disorder symptoms.

Using Chaplains to Facilitate Advance Care Planning in Medical Practice

fore were considered to have dropped out of the study. Depression negatively correlated (P = .05) and baseline marijuana use positively correlated (P = .04) with study completion. The Table provides characteristics and results for the sample; we found no sex association with study completion or opioid reduction. Among study completers (n = 51) baseline median MEDD (interquartile range [IQR]) was 288 (153-587) mg, with a median 6-year duration (IQR, 3-9) duration of opioid use. Median pain intensity was moderate (5 out of 10 on a numeric pain rating). After 4 months, the median MEDD was reduced to 150 (IQR, 54-248) mg (P = .002). The likelihood of a greater than 50% opioid dose reduction was not predicted by starting dose, baseline pain intensity, years prescribed opioids, or any psychosocial variable. Neither pain intensity (P = .29) nor pain interference (P = .44) increased with opioid reduction. The Figure shows the relationship between percentage change in MEDD and pain intensity in study completers.

Survival Prediction in Ambulatory Patients With Stage III/IV Non-Small Cell Lung Cancer Using the Palliative Performance Scale, ECOG, and Lung Cancer Symptom Scale

Objectives: Patients with advanced non-small cell lung cancer (NSCLC) have a life expectancy of less than 1 year. Therefore, it is important to maximize their quality of life and find a tool that can more accurately predict survival. Materials: The Palliative Performance Scale (PPS) is used to predict survival for patients with advanced disease based on functional dimensions. The value of the PPS in ambulatory patients with cancer has not been examined to date. The Lung Cancer Symptom Scale (LCSS) measures six major symptoms and their effect on symptomatic distress and activity. We evaluated 62 patients with stage III or IV NSCLC and Eastern Cooperative Oncology Group (ECOG) Scale Score ≥1 at baseline in a thoracic oncology clinic. In all, 62 patients had LCSS and PPS evaluated at baseline and 54 patients had 4-week follow-up using LCSS, PPS, and ECOG. Results: Fifty-four patients completed baseline and follow-up. Mean age was 63.7 years. Sixty-three percent were receiving chemotherapy at evaluation. Seventeen patients died. Mean baseline measures were LCSS 6.18 (1-14); PPS 66.6 (40-90); and ECOG 1.82 (1-4). Censored survival times were calculated from enrollment of the first patient for 380 days. A proportional hazardous model was computed for survival status. Hazard ratios for death were 1.25 (P = .013) for LCSS, 2.12 (P = .027) for ECOG, and 1.02 for PPS (P = .49). Conclusions: The LCSS predicted prognosis best in this study. The PPS did not accurately predict prognosis in our patient population.

Anger Proneness and Prognostic Pessimism in Men With Prostate Cancer

Aim: Anger is a common reaction to cancer diagnosis which may impact patients’ perceptions of their prognosis and goals of care. This study tested the hypothesis that men with prostate cancer who are anger prone are pessimistic regarding their cancer prognosis. Methods: Two hundred and twelve men with a history of prostate cancer completed measures of personality traits, their prostate cancer prognosis, and their perception of their doctor’s assessment of their prognosis. Anger proneness was operationally defined by the presence of high levels (ie, above the medians) of neuroticism and disagreeableness. Results: One in 4 men with prostate cancer disagreed with their doctor about prognosis. Anger-prone participants endorsed more pessimistic perceptions of prognosis (P = .041). This significant association was maintained after accounting for potential confounders. Conclusion: Greater attention paid to patient anger regulation style and pessimistic perceptions will improve discussions about prognosis and goals of care among men with prostate cancer. Given recent calls for wider distress screening and earlier palliative care intervention in cancer settings, providers have an unprecedented opportunity to assess and respond to anger in the clinical setting. Communication could be improved through empathic statements that convey realistic optimism when appropriate, a commitment to the patient–provider relationship and a willingness to explore and address patient needs.

Cultural Differences in Discussion of Do-not-resuscitate Status and Hospice

Previous research has shown that African American and Latino populations prefer more aggressive care at end of life. The purpose of this retrospective chart review was to describe whether having a palliative care consultation affected acceptance of do-not-resuscitate (DNR) status and hospice in these populations. Data were extracted from the medical records of patients who received a palliative care consultation between March 2011 and July 2011. Data extracted were race, age, gender, primary disease process, DNR status at time of consult and at discharge, and whether the patient enrolled in hospice if eligible. Demographic variables were tabulated using descriptive statistics or frequency distributions where appropriate. t Tests and analyses of variance were conducted to examine differences between ethnic groups. The sample size was 199, of which 38% were African American and 15% Hispanic. Prior to consultation, there were statistically significant differences regarding DNR status; after consultation, there were no differences in acceptance of DNR among races. Statistically significant differences among ethnicities remained in hospice enrollment. The authors conclude that palliative care consultations make a significant difference in this patient population. Further research is needed to identify why having a palliative care consultation impacted the decision about code status.

Compassion Fatigue Among Palliative Care Clinicians: Findings on Personality Factors and Years of Service:

Objectives: Palliative medicine is a rewarding field, but providers encounter patient trauma on a routine basis. Compassion fatigue, marked by burnout, secondary traumatic stress, and low satisfaction may result. However, professionals differ markedly in how they respond to patient trauma. The objective of the current study was to determine whether personality traits of neuroticism and agreeableness relate to aspects of compassion fatigue, after accounting for time spent working in the field. Methods: Sixty-six palliative medicine physicians, nurses, social workers, and chaplains completed validated measures of personality traits, compassion fatigue, and work background. Results: Providers who had worked longer reported higher levels of satisfaction and lower levels of burnout. Neuroticism demonstrated strong significant associations with secondary traumatic stress and burnout (Ps < .001). Agreeableness was significantly and strongly associated with compassion satisfaction (P < .001). These associations held after accounting for years spent working in the field. Significance of Results: Personality traits of neuroticism and agreeableness may convey risk and resilience, respectively, for palliative care professionals. More research is needed to determine if assessing personality traits can help identify providers at risk for adverse reactions to patient trauma.

Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams

Background: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. Objective: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. Methods: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. Results: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US

Sleep Disturbance Mediates the Association of Post-Traumatic Stress Disorder Symptoms and Pain in Patients With Cancer

6643 vs US

Palliative Workforce Development and a Regional Training Program

12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. Conclusion: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.