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Paradigm shifts in palliative care
Better engagement with patients essential
A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.
The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.
This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?
Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .
Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.
James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”
That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.
“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.
“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”
Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.
“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
Varieties of pain
Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.
Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.
The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.
“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”
Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.
Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”
Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.
In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.
“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”
When it comes right down to it, she said, patients want a better life, not their drug of choice.
“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”
People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.
“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.
“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
Paradigm shift
Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.
Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.
“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.
The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.
In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.
“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.
More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.
In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.1
In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.2
Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.
These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.
Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.
Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.
The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.
“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”3
References
1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.
2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.
3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).
Better engagement with patients essential
Better engagement with patients essential
A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.
The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.
This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?
Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .
Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.
James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”
That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.
“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.
“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”
Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.
“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
Varieties of pain
Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.
Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.
The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.
“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”
Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.
Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”
Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.
In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.
“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”
When it comes right down to it, she said, patients want a better life, not their drug of choice.
“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”
People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.
“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.
“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
Paradigm shift
Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.
Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.
“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.
The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.
In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.
“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.
More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.
In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.1
In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.2
Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.
These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.
Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.
Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.
The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.
“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”3
References
1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.
2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.
3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).
A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.
The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.
This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?
Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .
Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.
James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”
That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.
“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.
“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”
Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.
“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
Varieties of pain
Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.
Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.
The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.
“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”
Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.
Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”
Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.
In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.
“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”
When it comes right down to it, she said, patients want a better life, not their drug of choice.
“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”
People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.
“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.
“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
Paradigm shift
Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.
Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.
“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.
The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.
In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.
“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.
More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.
In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.1
In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.2
Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.
These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.
Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.
Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.
The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.
“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”3
References
1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.
2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.
3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).
Surgical palliative care – 20 years on
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.
The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.
Kill the suffering, not the patient
It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.
Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.
Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.
Hope in fellowship
Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.
Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.
We have come a long way in 20 years but there are still miles to go before we sleep.
Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.
Association between hospice length of stay and health care costs
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Palliative care consultations reduce hospital costs
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Dehydration in terminal illness: Which path forward?
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; [email protected]
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; [email protected]
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; [email protected]
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
Lessons and Implications of Establishing A VA Cancer Biobanking Program
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Aromatherapy Evidence-Based Project On Inpatient Cancer/Palliative Care Unit
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Trends in Cancer Incidence and Survival in the Veterans Health Administration
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Standardization of the Discharge Process for Inpatient Hematology and Oncology
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Genomic Medicine Service Uses Group Telehealth Appointments to Reduce Wait Times From 5 Months To ~1 Week
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.