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American Academy of Hospice and Palliative Medicine (AAHPM): Annual Assembly
Lower costs documented in hospitals with palliative care programs
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (P less than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
"This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary," said Mr. Horton.
Mr. Horton reported having no financial disclosures.
AT THE AAHPM ANNUAL ASSEMBLY
Major finding: ICU length of stay in the last 6 months of life was 0.4 days shorter and hospice length of stay was 1.6 days longer at hospitals with palliative care (P less than .001, P = .013).
Data source: A retrospective analysis of 3,593 hospitals with palliative care data.
Disclosures: Mr. Horton reported having no financial disclosures.
Need is dire for palliative care in disaster planning
NEW ORLEANS – In a room filled with roughly 2,000 health care providers, just a dozen or so hands went up when the audience was asked whether their hospital or state had a "crisis standards of care" protocol.
"That’s actually very common, because the problem with some of these protocols is that very few people know that they exist, which makes it hard to implement them in a time of crisis," Dr. Sheri Fink said during a disaster preparedness plenary session at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Dr. Fink and other experts made the case for a wider discussion of the often agonizing decisions health care providers face when natural disasters disrupt delivery of care. For example: After "superstorm" Hurricane Sandy last fall, providers at one hospital were warned of the possibility they might be faced with having just six functioning power outlets for 56 ICU patients. No one should have to make that kind of call alone, the experts contend.
The Institute of Medicine (IOM) issued a 2009 report in the wake of Hurricane Katrina defining crisis standards of care (CSC), and followed it up last year with a series of templates to guide those responsible for CSC planning and implementation.
Many CSC protocols call for withdrawing patients from scarce resources, and offer guidance on how to score patients for resource allocation and evacuation. Very little research is available, however, to support these triage protocols, and most fail to discuss the practical removal of care, according to Dr. Fink, a senior fellow at the Harvard Humanitarian Initiative who earned a 2010 Pulitzer prize for investigative reporting on the deadly choices made after Katrina at Memorial Medical Center in New Orleans.
"All of you here who have engaged in end-of-life discussions, who’ve dealt with withdrawing patients from ventilators where the care is futile, know just how hard it is to help the family wrap their mind around that," she said. "Just imagine being in a disaster when you have to do that, and there’s a reasonable chance that the patient could survive."
In New Orleans, the sickest of the sick with a DNR (do not resuscitate) order were taken out last from Memorial Hospital – but no one asked them or their families, thus violating patient autonomy. Some families who found out about the decision begged to have the DNR rescinded and their loved ones moved. After Sandy, some hospitals planned to evacuate the sickest; but after triaging patients and explaining the scope of the disaster to families, they found that many families let other patients go first, Dr. Fink said.
"DNR orders aren’t necessarily a great triage," she said. "They tell you about the patient’s foresight about dying, not about their ability to survive."
Hospitals understand the need to have redundant communication systems and off-site drug supplies, but they may not think about such practical issues as the weight of their patients, said Marianne Matzo, Ph.D., chair of palliative care nursing at the University of Oklahoma Health Sciences Center College of Nursing in Oklahoma City, and a member of the IOM committee that crafted the CSC templates.
During Katrina, emergency cots broke under the weight of obese patients, while helicopter pilots told hospital staff they could evacuate two obese patients or four normal-weight patients. After Sandy, two obese patients had to be sheltered in place at Bellevue Hospital in New York because they were too heavy to be transported out once the electricity went out.
In the face of America’s obesity epidemic, a first step in triage may be to move heavier patients to lower floors, before the elevators stop working, she said.
The IOM has convened a new committee to look at what triggers the activation of CSC protocols. During Sandy, the trigger was the same, but the responses varied. The Veterans Health Administration evacuated its patients before the storm, Bellevue evacuated patients after the storm and, unfortunately, New York University evacuated patients during the storm, Dr. Matzo said.
Both women pointed to the need for greater discourse and education among physicians and the public about disaster planning, response, and recovery.
Vital education for all first responders and providers should include how to access medication stockpiles, how to titrate opiates for patients in pain and near death, how to use medications to manage symptoms so an individual experiences a comfortable death, and basics in psychosocial counseling and support for peer-to-peer and provider/patient services under mass casualty event scenarios, Dr. Matzo said.
When disaster planners make decisions about which patients will and will not get access to lifesaving resources without the help of palliative care experts, Dr. Fink said, "it’s just sort of assumed that the default is that everyone else will get palliated."
However, the lesson learned from New Orleans and other recent U.S. disasters is that few actually do.
Dr. Fink and Dr. Matzo reported no relevant disclosures.
It seems that there are two broad categories of disasters: mass-casualty events (in which our existing health care infrastructure is not compromised) and natural disasters (in which the infrastructure as well as safety of patients, health care providers and their families may be at risk).
In both cases, we are learning from each successive event (as demonstrated by the Dr. Fink reporting and by efforts to standardize the approach to ethical dilemmas, triage, etc). Having been at war for the last 10 or so years has improved coordination of response at the community and health care system level.
During a disaster, we can really only follow our training and care for the patients in our institutions. Going forward, it is imperative that hospitalists be involved in disaster-planning efforts in their respective institutions.
Hospitalists may be asked to help determine when and if to deploy scarce resources, and as such should advocate for institutional or perhaps statewide standards. This keeps the onus for making these decisions off individual physicians. The Institute of Medicine's initial efforts at producing such standards can be found at tinyurl.com/IOMCrisis.
Leigh Fredholm, M.D., is a codirector of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. She is coauthor of the Palliatively Speaking blog for Hospitalist News.
It seems that there are two broad categories of disasters: mass-casualty events (in which our existing health care infrastructure is not compromised) and natural disasters (in which the infrastructure as well as safety of patients, health care providers and their families may be at risk).
In both cases, we are learning from each successive event (as demonstrated by the Dr. Fink reporting and by efforts to standardize the approach to ethical dilemmas, triage, etc). Having been at war for the last 10 or so years has improved coordination of response at the community and health care system level.
During a disaster, we can really only follow our training and care for the patients in our institutions. Going forward, it is imperative that hospitalists be involved in disaster-planning efforts in their respective institutions.
Hospitalists may be asked to help determine when and if to deploy scarce resources, and as such should advocate for institutional or perhaps statewide standards. This keeps the onus for making these decisions off individual physicians. The Institute of Medicine's initial efforts at producing such standards can be found at tinyurl.com/IOMCrisis.
Leigh Fredholm, M.D., is a codirector of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. She is coauthor of the Palliatively Speaking blog for Hospitalist News.
It seems that there are two broad categories of disasters: mass-casualty events (in which our existing health care infrastructure is not compromised) and natural disasters (in which the infrastructure as well as safety of patients, health care providers and their families may be at risk).
In both cases, we are learning from each successive event (as demonstrated by the Dr. Fink reporting and by efforts to standardize the approach to ethical dilemmas, triage, etc). Having been at war for the last 10 or so years has improved coordination of response at the community and health care system level.
During a disaster, we can really only follow our training and care for the patients in our institutions. Going forward, it is imperative that hospitalists be involved in disaster-planning efforts in their respective institutions.
Hospitalists may be asked to help determine when and if to deploy scarce resources, and as such should advocate for institutional or perhaps statewide standards. This keeps the onus for making these decisions off individual physicians. The Institute of Medicine's initial efforts at producing such standards can be found at tinyurl.com/IOMCrisis.
Leigh Fredholm, M.D., is a codirector of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. She is coauthor of the Palliatively Speaking blog for Hospitalist News.
NEW ORLEANS – In a room filled with roughly 2,000 health care providers, just a dozen or so hands went up when the audience was asked whether their hospital or state had a "crisis standards of care" protocol.
"That’s actually very common, because the problem with some of these protocols is that very few people know that they exist, which makes it hard to implement them in a time of crisis," Dr. Sheri Fink said during a disaster preparedness plenary session at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Dr. Fink and other experts made the case for a wider discussion of the often agonizing decisions health care providers face when natural disasters disrupt delivery of care. For example: After "superstorm" Hurricane Sandy last fall, providers at one hospital were warned of the possibility they might be faced with having just six functioning power outlets for 56 ICU patients. No one should have to make that kind of call alone, the experts contend.
The Institute of Medicine (IOM) issued a 2009 report in the wake of Hurricane Katrina defining crisis standards of care (CSC), and followed it up last year with a series of templates to guide those responsible for CSC planning and implementation.
Many CSC protocols call for withdrawing patients from scarce resources, and offer guidance on how to score patients for resource allocation and evacuation. Very little research is available, however, to support these triage protocols, and most fail to discuss the practical removal of care, according to Dr. Fink, a senior fellow at the Harvard Humanitarian Initiative who earned a 2010 Pulitzer prize for investigative reporting on the deadly choices made after Katrina at Memorial Medical Center in New Orleans.
"All of you here who have engaged in end-of-life discussions, who’ve dealt with withdrawing patients from ventilators where the care is futile, know just how hard it is to help the family wrap their mind around that," she said. "Just imagine being in a disaster when you have to do that, and there’s a reasonable chance that the patient could survive."
In New Orleans, the sickest of the sick with a DNR (do not resuscitate) order were taken out last from Memorial Hospital – but no one asked them or their families, thus violating patient autonomy. Some families who found out about the decision begged to have the DNR rescinded and their loved ones moved. After Sandy, some hospitals planned to evacuate the sickest; but after triaging patients and explaining the scope of the disaster to families, they found that many families let other patients go first, Dr. Fink said.
"DNR orders aren’t necessarily a great triage," she said. "They tell you about the patient’s foresight about dying, not about their ability to survive."
Hospitals understand the need to have redundant communication systems and off-site drug supplies, but they may not think about such practical issues as the weight of their patients, said Marianne Matzo, Ph.D., chair of palliative care nursing at the University of Oklahoma Health Sciences Center College of Nursing in Oklahoma City, and a member of the IOM committee that crafted the CSC templates.
During Katrina, emergency cots broke under the weight of obese patients, while helicopter pilots told hospital staff they could evacuate two obese patients or four normal-weight patients. After Sandy, two obese patients had to be sheltered in place at Bellevue Hospital in New York because they were too heavy to be transported out once the electricity went out.
In the face of America’s obesity epidemic, a first step in triage may be to move heavier patients to lower floors, before the elevators stop working, she said.
The IOM has convened a new committee to look at what triggers the activation of CSC protocols. During Sandy, the trigger was the same, but the responses varied. The Veterans Health Administration evacuated its patients before the storm, Bellevue evacuated patients after the storm and, unfortunately, New York University evacuated patients during the storm, Dr. Matzo said.
Both women pointed to the need for greater discourse and education among physicians and the public about disaster planning, response, and recovery.
Vital education for all first responders and providers should include how to access medication stockpiles, how to titrate opiates for patients in pain and near death, how to use medications to manage symptoms so an individual experiences a comfortable death, and basics in psychosocial counseling and support for peer-to-peer and provider/patient services under mass casualty event scenarios, Dr. Matzo said.
When disaster planners make decisions about which patients will and will not get access to lifesaving resources without the help of palliative care experts, Dr. Fink said, "it’s just sort of assumed that the default is that everyone else will get palliated."
However, the lesson learned from New Orleans and other recent U.S. disasters is that few actually do.
Dr. Fink and Dr. Matzo reported no relevant disclosures.
NEW ORLEANS – In a room filled with roughly 2,000 health care providers, just a dozen or so hands went up when the audience was asked whether their hospital or state had a "crisis standards of care" protocol.
"That’s actually very common, because the problem with some of these protocols is that very few people know that they exist, which makes it hard to implement them in a time of crisis," Dr. Sheri Fink said during a disaster preparedness plenary session at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Dr. Fink and other experts made the case for a wider discussion of the often agonizing decisions health care providers face when natural disasters disrupt delivery of care. For example: After "superstorm" Hurricane Sandy last fall, providers at one hospital were warned of the possibility they might be faced with having just six functioning power outlets for 56 ICU patients. No one should have to make that kind of call alone, the experts contend.
The Institute of Medicine (IOM) issued a 2009 report in the wake of Hurricane Katrina defining crisis standards of care (CSC), and followed it up last year with a series of templates to guide those responsible for CSC planning and implementation.
Many CSC protocols call for withdrawing patients from scarce resources, and offer guidance on how to score patients for resource allocation and evacuation. Very little research is available, however, to support these triage protocols, and most fail to discuss the practical removal of care, according to Dr. Fink, a senior fellow at the Harvard Humanitarian Initiative who earned a 2010 Pulitzer prize for investigative reporting on the deadly choices made after Katrina at Memorial Medical Center in New Orleans.
"All of you here who have engaged in end-of-life discussions, who’ve dealt with withdrawing patients from ventilators where the care is futile, know just how hard it is to help the family wrap their mind around that," she said. "Just imagine being in a disaster when you have to do that, and there’s a reasonable chance that the patient could survive."
In New Orleans, the sickest of the sick with a DNR (do not resuscitate) order were taken out last from Memorial Hospital – but no one asked them or their families, thus violating patient autonomy. Some families who found out about the decision begged to have the DNR rescinded and their loved ones moved. After Sandy, some hospitals planned to evacuate the sickest; but after triaging patients and explaining the scope of the disaster to families, they found that many families let other patients go first, Dr. Fink said.
"DNR orders aren’t necessarily a great triage," she said. "They tell you about the patient’s foresight about dying, not about their ability to survive."
Hospitals understand the need to have redundant communication systems and off-site drug supplies, but they may not think about such practical issues as the weight of their patients, said Marianne Matzo, Ph.D., chair of palliative care nursing at the University of Oklahoma Health Sciences Center College of Nursing in Oklahoma City, and a member of the IOM committee that crafted the CSC templates.
During Katrina, emergency cots broke under the weight of obese patients, while helicopter pilots told hospital staff they could evacuate two obese patients or four normal-weight patients. After Sandy, two obese patients had to be sheltered in place at Bellevue Hospital in New York because they were too heavy to be transported out once the electricity went out.
In the face of America’s obesity epidemic, a first step in triage may be to move heavier patients to lower floors, before the elevators stop working, she said.
The IOM has convened a new committee to look at what triggers the activation of CSC protocols. During Sandy, the trigger was the same, but the responses varied. The Veterans Health Administration evacuated its patients before the storm, Bellevue evacuated patients after the storm and, unfortunately, New York University evacuated patients during the storm, Dr. Matzo said.
Both women pointed to the need for greater discourse and education among physicians and the public about disaster planning, response, and recovery.
Vital education for all first responders and providers should include how to access medication stockpiles, how to titrate opiates for patients in pain and near death, how to use medications to manage symptoms so an individual experiences a comfortable death, and basics in psychosocial counseling and support for peer-to-peer and provider/patient services under mass casualty event scenarios, Dr. Matzo said.
When disaster planners make decisions about which patients will and will not get access to lifesaving resources without the help of palliative care experts, Dr. Fink said, "it’s just sort of assumed that the default is that everyone else will get palliated."
However, the lesson learned from New Orleans and other recent U.S. disasters is that few actually do.
Dr. Fink and Dr. Matzo reported no relevant disclosures.
AT THE AAHPM ANNUAL ASSEMBLY
Dexamethasone eases end-of-life cancer-related fatigue
NEW ORLEANS – Dexamethasone was more effective than was placebo in relieving cancer-related fatigue in a double-blind randomized trial of patients with advanced cancer.
After 14 days of treatment, scores on the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue subscale improved by nearly 6 points in the dexamethasone group (9.0 vs. 3.1; P = .008).
"[Treatment] duration is very important in our patient population because when they are referred to us, it’s very late. They typically have a survival of just 28 to 7 days," Dr. Sriram Yennu said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Although 20%-50% of palliative care patients receive some form of corticosteroid, no steroid study to date has used cancer-related fatigue (CRF) as a primary outcome or assessed CRF with a validated outcome measure, he said. Fatigue is ubiquitous, however, contributing up to one-third of symptom distress in patients with advanced cancer.
The study enrolled 132 outpatients with a life expectancy of at least 4 weeks with three or more cancer-related symptoms (fatigue, pain, nausea, loss of appetite, depression, anxiety, or sleep disturbance), and randomly assigned them to oral dexamethasone 4 mg twice daily or placebo for 14 days.
The most common diagnosis was head and neck/lung cancer in 45 patients, followed by gastrointestinal cancer in 39, breast cancer in 13, and genitourinary in 10. Median patient age was 60; 81 patients were white, and the average FACIT fatigue score was 19.6, where 52 denotes no fatigue and 0 is severe fatigue.
Among 84 evaluable patients, total scores on FACIT favored the dexamethasone group (18.16 vs. 7.87; P = .03), as did scores on its physical subscale (5.25 vs. 1.32; P = .002), said Dr. Yennu of the department of palliative care and rehabilitation medicine, University of Texas MD Anderson Cancer Center, Houston.
Scores on the physical domain of the Edmonton Symptom Assessment Scale (ESAS) were better in the dexamethasone group than in the placebo group (–10.15 vs. –5.39; P = .04), according to the study, which earned Dr. Yennu a young investigator award.
Notably, scores were similar between the dexamethasone and placebo groups on the emotional subscale of FACIT (1.85 vs. 1.18; P = .49) and the ESAS psychological subscale (–1.48 vs. –2.08; P = .76). The emotional domain of the FACIT-F is measured by six items using a 0-4 scale where 0 is "not at all" and 4 includes statements like "I am losing hope in the fight against my illness." The finding suggests that the improvement in fatigue was likely not just a euphoric effect, as observed before in other steroid trials, Dr. Yennu said.
He expressed concern that corticosteroid use would increase toxicity, particularly insomnia, but no significant differences were observed between the dexamethasone and placebo groups regarding insomnia (3 vs. 4), overall adverse events (41 vs. 44) or serious adverse events (17 vs. 11).
Larger, long-term safety and efficacy studies are needed to address steroid dose and duration, and whether dexamethasone should be coupled with interventions targeting the psychological domain, he said. A 3-point difference in the FACIT is considered clinically important, but research in press in the Journal of Clinical Oncology, by Dr. Yennu and his colleagues, suggests a 10-point difference is more meaningful.
The American Cancer Society supported the study. Dr. Yennu reported having no financial disclosures.
NEW ORLEANS – Dexamethasone was more effective than was placebo in relieving cancer-related fatigue in a double-blind randomized trial of patients with advanced cancer.
After 14 days of treatment, scores on the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue subscale improved by nearly 6 points in the dexamethasone group (9.0 vs. 3.1; P = .008).
"[Treatment] duration is very important in our patient population because when they are referred to us, it’s very late. They typically have a survival of just 28 to 7 days," Dr. Sriram Yennu said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Although 20%-50% of palliative care patients receive some form of corticosteroid, no steroid study to date has used cancer-related fatigue (CRF) as a primary outcome or assessed CRF with a validated outcome measure, he said. Fatigue is ubiquitous, however, contributing up to one-third of symptom distress in patients with advanced cancer.
The study enrolled 132 outpatients with a life expectancy of at least 4 weeks with three or more cancer-related symptoms (fatigue, pain, nausea, loss of appetite, depression, anxiety, or sleep disturbance), and randomly assigned them to oral dexamethasone 4 mg twice daily or placebo for 14 days.
The most common diagnosis was head and neck/lung cancer in 45 patients, followed by gastrointestinal cancer in 39, breast cancer in 13, and genitourinary in 10. Median patient age was 60; 81 patients were white, and the average FACIT fatigue score was 19.6, where 52 denotes no fatigue and 0 is severe fatigue.
Among 84 evaluable patients, total scores on FACIT favored the dexamethasone group (18.16 vs. 7.87; P = .03), as did scores on its physical subscale (5.25 vs. 1.32; P = .002), said Dr. Yennu of the department of palliative care and rehabilitation medicine, University of Texas MD Anderson Cancer Center, Houston.
Scores on the physical domain of the Edmonton Symptom Assessment Scale (ESAS) were better in the dexamethasone group than in the placebo group (–10.15 vs. –5.39; P = .04), according to the study, which earned Dr. Yennu a young investigator award.
Notably, scores were similar between the dexamethasone and placebo groups on the emotional subscale of FACIT (1.85 vs. 1.18; P = .49) and the ESAS psychological subscale (–1.48 vs. –2.08; P = .76). The emotional domain of the FACIT-F is measured by six items using a 0-4 scale where 0 is "not at all" and 4 includes statements like "I am losing hope in the fight against my illness." The finding suggests that the improvement in fatigue was likely not just a euphoric effect, as observed before in other steroid trials, Dr. Yennu said.
He expressed concern that corticosteroid use would increase toxicity, particularly insomnia, but no significant differences were observed between the dexamethasone and placebo groups regarding insomnia (3 vs. 4), overall adverse events (41 vs. 44) or serious adverse events (17 vs. 11).
Larger, long-term safety and efficacy studies are needed to address steroid dose and duration, and whether dexamethasone should be coupled with interventions targeting the psychological domain, he said. A 3-point difference in the FACIT is considered clinically important, but research in press in the Journal of Clinical Oncology, by Dr. Yennu and his colleagues, suggests a 10-point difference is more meaningful.
The American Cancer Society supported the study. Dr. Yennu reported having no financial disclosures.
NEW ORLEANS – Dexamethasone was more effective than was placebo in relieving cancer-related fatigue in a double-blind randomized trial of patients with advanced cancer.
After 14 days of treatment, scores on the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue subscale improved by nearly 6 points in the dexamethasone group (9.0 vs. 3.1; P = .008).
"[Treatment] duration is very important in our patient population because when they are referred to us, it’s very late. They typically have a survival of just 28 to 7 days," Dr. Sriram Yennu said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Although 20%-50% of palliative care patients receive some form of corticosteroid, no steroid study to date has used cancer-related fatigue (CRF) as a primary outcome or assessed CRF with a validated outcome measure, he said. Fatigue is ubiquitous, however, contributing up to one-third of symptom distress in patients with advanced cancer.
The study enrolled 132 outpatients with a life expectancy of at least 4 weeks with three or more cancer-related symptoms (fatigue, pain, nausea, loss of appetite, depression, anxiety, or sleep disturbance), and randomly assigned them to oral dexamethasone 4 mg twice daily or placebo for 14 days.
The most common diagnosis was head and neck/lung cancer in 45 patients, followed by gastrointestinal cancer in 39, breast cancer in 13, and genitourinary in 10. Median patient age was 60; 81 patients were white, and the average FACIT fatigue score was 19.6, where 52 denotes no fatigue and 0 is severe fatigue.
Among 84 evaluable patients, total scores on FACIT favored the dexamethasone group (18.16 vs. 7.87; P = .03), as did scores on its physical subscale (5.25 vs. 1.32; P = .002), said Dr. Yennu of the department of palliative care and rehabilitation medicine, University of Texas MD Anderson Cancer Center, Houston.
Scores on the physical domain of the Edmonton Symptom Assessment Scale (ESAS) were better in the dexamethasone group than in the placebo group (–10.15 vs. –5.39; P = .04), according to the study, which earned Dr. Yennu a young investigator award.
Notably, scores were similar between the dexamethasone and placebo groups on the emotional subscale of FACIT (1.85 vs. 1.18; P = .49) and the ESAS psychological subscale (–1.48 vs. –2.08; P = .76). The emotional domain of the FACIT-F is measured by six items using a 0-4 scale where 0 is "not at all" and 4 includes statements like "I am losing hope in the fight against my illness." The finding suggests that the improvement in fatigue was likely not just a euphoric effect, as observed before in other steroid trials, Dr. Yennu said.
He expressed concern that corticosteroid use would increase toxicity, particularly insomnia, but no significant differences were observed between the dexamethasone and placebo groups regarding insomnia (3 vs. 4), overall adverse events (41 vs. 44) or serious adverse events (17 vs. 11).
Larger, long-term safety and efficacy studies are needed to address steroid dose and duration, and whether dexamethasone should be coupled with interventions targeting the psychological domain, he said. A 3-point difference in the FACIT is considered clinically important, but research in press in the Journal of Clinical Oncology, by Dr. Yennu and his colleagues, suggests a 10-point difference is more meaningful.
The American Cancer Society supported the study. Dr. Yennu reported having no financial disclosures.
AT THE AAHPM ANNUAL ASSEMBLY
Major finding: Scores on the FACIT fatigue subscale improved by an average of 6 points in patients treated with dexamethasone, compared with 3 points in patients treated with placebo.
Data source: Double-blind, randomized trial of 132 patients with advanced cancer.
Disclosures: The American Cancer Society supported the study. Dr. Yennu reported having no financial disclosures.
Prescription is futile: Medication burden remains high at end of life
NEW ORLEANS – Futile and duplicate medications remain a significant burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients.
At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.
Reducing futile and duplicate medications provides not only a cost benefit, but also a morbidity benefit because many of these patients are frail and sometimes unable to swallow, and these medications increase pill burden and may actually exacerbate the very symptoms you’re trying to treat, Nehal Munshi said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Based on the medical literature and personal experience, the patients’ medications were independently ranked by two expert palliative care physicians and one pharmacist as appropriate, questionable, futile, duplicate, or not enough patient data to support a ranking. Consensus was achieved where there were discrepancies.
Medications in the hospice emergency kit, also known as the e-kit, were omitted from the analysis. Duplication medications were defined as two agents prescribed for the same indication when one would have sufficed.
Patients in the study were drawn from six hospice agencies in Louisiana over a 6-month period. Their median age was 80 (range 23-107), 58% were women, 72% were white, 23% black, and 0.5% Hispanic. More than one-third of patients (37.3%) died within 2 weeks of study entry.
Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.
Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), and Sudafed.
Prior to hospice admission, patients were on a median of 7 medications, but as many as 27 separate medications, said Mr. Munshi, a fourth-year medical student at Tulane Medical School in New Orleans. It was not possible to determine whether the average number of medications was lower for those entering hospice after being cared for by a palliative care physician.
Hospices appeared to make little headway in reducing pill burden. Only 7.3% of patients with futile medications prior to hospice admission had such medications withdrawn in hospice care.
Stripping away unnecessary medications can actually increase well being among patients entering hospice, a phenomenon known as the "hospice bounce," Dr. Louis Lux, medical director of Hospice Compassus in Austin, and director of the internal medicine clerkship at Texas A&M Health Science Center in Round Rock, both in Texas, said during a discussion of the study. He suggested that it helps patients to understand that their bodies are changing and that you’re not taking away medications, but trying to improve their quality of life.
"Sometimes it’s a choice between being able to swallow a statin or an antiemetic," he said.
At the same time, Dr. Lux cautioned that many patients are invested in their medications, and that studies have shown that abrupt cessation of statins can increase the risk of cardiovascular events in some people.
Mr. Munshi agreed that medication reduction "needs to be a team approach" including the patient, the family, community physicians, specialists, and hospice providers, but suggested that policy and practice modifications aimed at reducing futile and duplication medications, not only after the transition to hospice but potentially much earlier or prior to starting a treatment, could yield substantial benefits.
The authors reported no relevant conflicts of interest.
NEW ORLEANS – Futile and duplicate medications remain a significant burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients.
At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.
Reducing futile and duplicate medications provides not only a cost benefit, but also a morbidity benefit because many of these patients are frail and sometimes unable to swallow, and these medications increase pill burden and may actually exacerbate the very symptoms you’re trying to treat, Nehal Munshi said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Based on the medical literature and personal experience, the patients’ medications were independently ranked by two expert palliative care physicians and one pharmacist as appropriate, questionable, futile, duplicate, or not enough patient data to support a ranking. Consensus was achieved where there were discrepancies.
Medications in the hospice emergency kit, also known as the e-kit, were omitted from the analysis. Duplication medications were defined as two agents prescribed for the same indication when one would have sufficed.
Patients in the study were drawn from six hospice agencies in Louisiana over a 6-month period. Their median age was 80 (range 23-107), 58% were women, 72% were white, 23% black, and 0.5% Hispanic. More than one-third of patients (37.3%) died within 2 weeks of study entry.
Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.
Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), and Sudafed.
Prior to hospice admission, patients were on a median of 7 medications, but as many as 27 separate medications, said Mr. Munshi, a fourth-year medical student at Tulane Medical School in New Orleans. It was not possible to determine whether the average number of medications was lower for those entering hospice after being cared for by a palliative care physician.
Hospices appeared to make little headway in reducing pill burden. Only 7.3% of patients with futile medications prior to hospice admission had such medications withdrawn in hospice care.
Stripping away unnecessary medications can actually increase well being among patients entering hospice, a phenomenon known as the "hospice bounce," Dr. Louis Lux, medical director of Hospice Compassus in Austin, and director of the internal medicine clerkship at Texas A&M Health Science Center in Round Rock, both in Texas, said during a discussion of the study. He suggested that it helps patients to understand that their bodies are changing and that you’re not taking away medications, but trying to improve their quality of life.
"Sometimes it’s a choice between being able to swallow a statin or an antiemetic," he said.
At the same time, Dr. Lux cautioned that many patients are invested in their medications, and that studies have shown that abrupt cessation of statins can increase the risk of cardiovascular events in some people.
Mr. Munshi agreed that medication reduction "needs to be a team approach" including the patient, the family, community physicians, specialists, and hospice providers, but suggested that policy and practice modifications aimed at reducing futile and duplication medications, not only after the transition to hospice but potentially much earlier or prior to starting a treatment, could yield substantial benefits.
The authors reported no relevant conflicts of interest.
NEW ORLEANS – Futile and duplicate medications remain a significant burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients.
At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.
Reducing futile and duplicate medications provides not only a cost benefit, but also a morbidity benefit because many of these patients are frail and sometimes unable to swallow, and these medications increase pill burden and may actually exacerbate the very symptoms you’re trying to treat, Nehal Munshi said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Based on the medical literature and personal experience, the patients’ medications were independently ranked by two expert palliative care physicians and one pharmacist as appropriate, questionable, futile, duplicate, or not enough patient data to support a ranking. Consensus was achieved where there were discrepancies.
Medications in the hospice emergency kit, also known as the e-kit, were omitted from the analysis. Duplication medications were defined as two agents prescribed for the same indication when one would have sufficed.
Patients in the study were drawn from six hospice agencies in Louisiana over a 6-month period. Their median age was 80 (range 23-107), 58% were women, 72% were white, 23% black, and 0.5% Hispanic. More than one-third of patients (37.3%) died within 2 weeks of study entry.
Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.
Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), and Sudafed.
Prior to hospice admission, patients were on a median of 7 medications, but as many as 27 separate medications, said Mr. Munshi, a fourth-year medical student at Tulane Medical School in New Orleans. It was not possible to determine whether the average number of medications was lower for those entering hospice after being cared for by a palliative care physician.
Hospices appeared to make little headway in reducing pill burden. Only 7.3% of patients with futile medications prior to hospice admission had such medications withdrawn in hospice care.
Stripping away unnecessary medications can actually increase well being among patients entering hospice, a phenomenon known as the "hospice bounce," Dr. Louis Lux, medical director of Hospice Compassus in Austin, and director of the internal medicine clerkship at Texas A&M Health Science Center in Round Rock, both in Texas, said during a discussion of the study. He suggested that it helps patients to understand that their bodies are changing and that you’re not taking away medications, but trying to improve their quality of life.
"Sometimes it’s a choice between being able to swallow a statin or an antiemetic," he said.
At the same time, Dr. Lux cautioned that many patients are invested in their medications, and that studies have shown that abrupt cessation of statins can increase the risk of cardiovascular events in some people.
Mr. Munshi agreed that medication reduction "needs to be a team approach" including the patient, the family, community physicians, specialists, and hospice providers, but suggested that policy and practice modifications aimed at reducing futile and duplication medications, not only after the transition to hospice but potentially much earlier or prior to starting a treatment, could yield substantial benefits.
The authors reported no relevant conflicts of interest.
AT THE AAHPM ANNUAL ASSEMBLY
Major finding: At some point in their end of life care, 39% of patients received futile medications and 19% received duplicate medications.
Data source: Blinded, prospective cohort study of 397 consecutive hospice patients.
Disclosures: The authors reported no relevant conflicts of interest.
What's in a name: Is the moniker 'palliative care' too loaded?
NEW ORLEANS – That which we call a rose by any other name would smell as sweet. Perhaps not, if the conversation turns to palliative care.
A telephone survey of 169 patients with advanced cancer found that those randomized to hear the term "supportive care" instead of "palliative care" rated their understanding, overall impressions and future perceived need for those services significantly higher.
In contrast, there was no significant difference in outcomes when patients heard either a "patient-centered" or "traditional" description of palliative/supportive care services, Rachael Maciasz said at the annual meeting of the American Association of Hospice and Palliative Medicine.
"It may be that ‘palliative care’ is so loaded with advanced cancer patients because of family members’ or friends’ experiences with this in the past that [they think] their family member is going to die," she said. "Perhaps what comes after that, no matter how you describe it, you can’t change that impression."
Patients with stage IV solid tumors or refractory/recurrent hematologic malignancies were recruited from 20 oncologists at two comprehensive cancer centers in Pittsburgh, and randomized to one of four survey groups: "palliative care/patient-centered," "palliative care/traditional," "supportive care/patient-centered," and "supportive care/traditional." Outcomes were measured using 10-point Likert scales, with 0 meaning "do not understand at all," or impression "not favorable at all" or "strongly disagree with" a need for services.
The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%).
The majority (63%) of patients were female, 95% were white, 88% were Catholic/Christian, 4% Jewish, and 7% other religion or agnostic. The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%). Their average age was 62 and roughly 11% had prior exposure to palliative care services.
The supportive care groups had significantly higher mean ratings than did the palliative care groups for overall understanding of what the service had to offer (7.7 vs. 6.8) and for overall favorable impressions (8.4 vs. 7.3), said Ms. Maciasz, a fourth-year medical student and a Doris Duke Clinical Research Fellow at the University of Pittsburgh.
Patients rated their current need for supportive and palliative care services equally, but were significantly more likely to perceive a future need for supportive services for themselves or family (8.6 vs. 7.7).
All patients rated their willingness to see a supportive/palliative care specialist as higher if their oncologist recommended it rather than if they had to ask their oncologist whether they could see a specialist on their own (8.6 vs. 6.0).
In a robust multivariable regression model that adjusted for term, description, and all significant variables in univariate analyses, the term supportive care was again significantly associated with more favorable impressions (correlation coefficient 1.24) and higher future perceived need (correlation coefficient 0.93), Ms. Maciasz said.
The qualitative results also paralleled the quantitative results.
"I had the impression that fewer patients went in with an impression of palliative care and that if you could explain it in ways that made perfect sense and described how awesome it is, that it wouldn’t matter if it was [called] palliative or supportive," Ms. Maciasz said in an interview. "I think it’s just loaded, but I don’t think it’s unique to patients."
Research data have shown that some oncologists don’t like the term palliative care. "I think there’s something about the term palliative care that means I can’t give you everything you need," she suggested.
Ms. Maciasz and her coauthors reported having no financial disclosures.
NEW ORLEANS – That which we call a rose by any other name would smell as sweet. Perhaps not, if the conversation turns to palliative care.
A telephone survey of 169 patients with advanced cancer found that those randomized to hear the term "supportive care" instead of "palliative care" rated their understanding, overall impressions and future perceived need for those services significantly higher.
In contrast, there was no significant difference in outcomes when patients heard either a "patient-centered" or "traditional" description of palliative/supportive care services, Rachael Maciasz said at the annual meeting of the American Association of Hospice and Palliative Medicine.
"It may be that ‘palliative care’ is so loaded with advanced cancer patients because of family members’ or friends’ experiences with this in the past that [they think] their family member is going to die," she said. "Perhaps what comes after that, no matter how you describe it, you can’t change that impression."
Patients with stage IV solid tumors or refractory/recurrent hematologic malignancies were recruited from 20 oncologists at two comprehensive cancer centers in Pittsburgh, and randomized to one of four survey groups: "palliative care/patient-centered," "palliative care/traditional," "supportive care/patient-centered," and "supportive care/traditional." Outcomes were measured using 10-point Likert scales, with 0 meaning "do not understand at all," or impression "not favorable at all" or "strongly disagree with" a need for services.
The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%).
The majority (63%) of patients were female, 95% were white, 88% were Catholic/Christian, 4% Jewish, and 7% other religion or agnostic. The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%). Their average age was 62 and roughly 11% had prior exposure to palliative care services.
The supportive care groups had significantly higher mean ratings than did the palliative care groups for overall understanding of what the service had to offer (7.7 vs. 6.8) and for overall favorable impressions (8.4 vs. 7.3), said Ms. Maciasz, a fourth-year medical student and a Doris Duke Clinical Research Fellow at the University of Pittsburgh.
Patients rated their current need for supportive and palliative care services equally, but were significantly more likely to perceive a future need for supportive services for themselves or family (8.6 vs. 7.7).
All patients rated their willingness to see a supportive/palliative care specialist as higher if their oncologist recommended it rather than if they had to ask their oncologist whether they could see a specialist on their own (8.6 vs. 6.0).
In a robust multivariable regression model that adjusted for term, description, and all significant variables in univariate analyses, the term supportive care was again significantly associated with more favorable impressions (correlation coefficient 1.24) and higher future perceived need (correlation coefficient 0.93), Ms. Maciasz said.
The qualitative results also paralleled the quantitative results.
"I had the impression that fewer patients went in with an impression of palliative care and that if you could explain it in ways that made perfect sense and described how awesome it is, that it wouldn’t matter if it was [called] palliative or supportive," Ms. Maciasz said in an interview. "I think it’s just loaded, but I don’t think it’s unique to patients."
Research data have shown that some oncologists don’t like the term palliative care. "I think there’s something about the term palliative care that means I can’t give you everything you need," she suggested.
Ms. Maciasz and her coauthors reported having no financial disclosures.
NEW ORLEANS – That which we call a rose by any other name would smell as sweet. Perhaps not, if the conversation turns to palliative care.
A telephone survey of 169 patients with advanced cancer found that those randomized to hear the term "supportive care" instead of "palliative care" rated their understanding, overall impressions and future perceived need for those services significantly higher.
In contrast, there was no significant difference in outcomes when patients heard either a "patient-centered" or "traditional" description of palliative/supportive care services, Rachael Maciasz said at the annual meeting of the American Association of Hospice and Palliative Medicine.
"It may be that ‘palliative care’ is so loaded with advanced cancer patients because of family members’ or friends’ experiences with this in the past that [they think] their family member is going to die," she said. "Perhaps what comes after that, no matter how you describe it, you can’t change that impression."
Patients with stage IV solid tumors or refractory/recurrent hematologic malignancies were recruited from 20 oncologists at two comprehensive cancer centers in Pittsburgh, and randomized to one of four survey groups: "palliative care/patient-centered," "palliative care/traditional," "supportive care/patient-centered," and "supportive care/traditional." Outcomes were measured using 10-point Likert scales, with 0 meaning "do not understand at all," or impression "not favorable at all" or "strongly disagree with" a need for services.
The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%).
The majority (63%) of patients were female, 95% were white, 88% were Catholic/Christian, 4% Jewish, and 7% other religion or agnostic. The most common cancer diagnoses were breast (32%), lung (18%), and gastrointestinal (13%). Their average age was 62 and roughly 11% had prior exposure to palliative care services.
The supportive care groups had significantly higher mean ratings than did the palliative care groups for overall understanding of what the service had to offer (7.7 vs. 6.8) and for overall favorable impressions (8.4 vs. 7.3), said Ms. Maciasz, a fourth-year medical student and a Doris Duke Clinical Research Fellow at the University of Pittsburgh.
Patients rated their current need for supportive and palliative care services equally, but were significantly more likely to perceive a future need for supportive services for themselves or family (8.6 vs. 7.7).
All patients rated their willingness to see a supportive/palliative care specialist as higher if their oncologist recommended it rather than if they had to ask their oncologist whether they could see a specialist on their own (8.6 vs. 6.0).
In a robust multivariable regression model that adjusted for term, description, and all significant variables in univariate analyses, the term supportive care was again significantly associated with more favorable impressions (correlation coefficient 1.24) and higher future perceived need (correlation coefficient 0.93), Ms. Maciasz said.
The qualitative results also paralleled the quantitative results.
"I had the impression that fewer patients went in with an impression of palliative care and that if you could explain it in ways that made perfect sense and described how awesome it is, that it wouldn’t matter if it was [called] palliative or supportive," Ms. Maciasz said in an interview. "I think it’s just loaded, but I don’t think it’s unique to patients."
Research data have shown that some oncologists don’t like the term palliative care. "I think there’s something about the term palliative care that means I can’t give you everything you need," she suggested.
Ms. Maciasz and her coauthors reported having no financial disclosures.
AT THE AAHPM ANNUAL ASSEMBLY
Major finding: The term supportive care was rated significantly higher than palliative care for overall understanding (mean 7.7 vs. 6.8; P = .021), favorable impressions (mean 8.4 vs. 7.3; P = .002) and perceived future need (8.6 vs. 7.7; P = .017).
Data source: Randomized 2X2 factorial telephone survey of 169 patients with advanced cancer.
Disclosures: The authors reported having no financial disclosures.
MOPAT may guide pain evaluation, relief in noncommunicative patients
NEW ORLEANS – The Multidimensional Objective Pain Assessment Tool can be used to assess and guide relief of acute pain in noncommunicative hospice patients in an inpatient setting, a study has shown.
"The MOPAT was reliable, fast, and clinically useful," Deborah McGuire, Ph.D., said at the annual assembly of the American Academy of Hospice and Palliative Medicine.
Assessing pain in patients who can not self-report their pain is a continuing clinical challenge, she observed. There are few validated assessment tools, and the limited research that is available is typically in partially cognitively impaired patients, limiting the ability to extrapolate the findings to patients who are fully cognitively impaired.
To address this gap, investigators at the University of Maryland School of Nursing in Baltimore validated the MOPAT, which consists of a four-item behavioral dimension ranked on a 3-point scale with 0 being none and 3 severe, and a three-item physiologic dimension rated as "no change from usual" or "change from usual." Both dimensions are summed for a total score of pain severity.
As part of the hospital study, staff and study nurses also used the MOPAT before and after pharmacologic and nonpharmacologic pain interventions in 100 patients admitted to a community-based hospice in a noncommunicative state and receiving palliative care for a diagnosis or condition known to cause acute pain.
Their average age was 72.6 years (range, 35-99 years); 61% were women; 92% were white; and 53% were in the active/terminal phase of dying. Other reasons for noncommunication included expressive/receptive aphasia (15%), metabolic encephalopathy (7%), stroke (6%), malignancy (5%), and delirium (5%). Pain was typically due to functional activities such as bathing and turning patients (57.3%), followed by inadequate analgesia in 31% and other reasons in 12%.
Agreement between staff and study nurses on pain ratings before and after the pain interventions was generally good on both the behavioral dimension (61.2% vs. 73.3%) and physiologic dimension (79.6% vs. 78%), said Dr. McGuire, professor of nursing at the university.
Results for internal consistency were acceptable for the behavioral dimension (alpha coefficient, 0.77 for study nurses and 0.81 for staff nurses) and for the overall scores (0.77), but not for the physiologic dimension (0.44 for study nurses; 0.63 for staff nurses). The inability to scale the severity of physiologic indicators likely contributed to the low alpha coefficients for this dimension, she said, adding in an interview that the dimension is currently being revised for the investigators’ next study.
Still, pain scores as rated by staff nurses decreased significantly after the pain interventions on the behavioral (mean, 6.3 vs. 1.7) and physiologic dimensions (mean, 1.49 vs. 0.89), indicating that "the MOPAT was sensitive to changes in pain and therefore a good measure of pain severity," Dr. McGuire said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
When surveyed on how often they encountered patients unable to communicate, 64.5% of 62 nurses said frequently; 32%, occasionally; and 3.2%, constantly.
Using a five-point scale, nurses also reported that the MOPAT was easy to use (mean score, 3.86); was easy to understand (3.90); assisted in communicating to others about the patient’s pain (3.67); and was helpful in determining whether the patient might need a pain relief intervention (3.64).
Dr. McGuire noted that the Hospice of Lancaster County (Pa.) has incorporated the MOPAT into its pain standard of care in the inpatient units and the home setting, and that it will be tested in combination with analgesic order sets in 22 different hospital inpatient units to examine pain-related outcomes such as severity and treatment choice.
"What we are aiming at in our longer-term program of research is to be able to find a simple tool that can be used to assess pain in people who can’t self-report across various settings in which palliative care is given – not just acute care or hospice," she said.
The National Institute of Nursing Research sponsored the study. Dr. McGuire and her coauthors reported no relevant financial disclosures.
NEW ORLEANS – The Multidimensional Objective Pain Assessment Tool can be used to assess and guide relief of acute pain in noncommunicative hospice patients in an inpatient setting, a study has shown.
"The MOPAT was reliable, fast, and clinically useful," Deborah McGuire, Ph.D., said at the annual assembly of the American Academy of Hospice and Palliative Medicine.
Assessing pain in patients who can not self-report their pain is a continuing clinical challenge, she observed. There are few validated assessment tools, and the limited research that is available is typically in partially cognitively impaired patients, limiting the ability to extrapolate the findings to patients who are fully cognitively impaired.
To address this gap, investigators at the University of Maryland School of Nursing in Baltimore validated the MOPAT, which consists of a four-item behavioral dimension ranked on a 3-point scale with 0 being none and 3 severe, and a three-item physiologic dimension rated as "no change from usual" or "change from usual." Both dimensions are summed for a total score of pain severity.
As part of the hospital study, staff and study nurses also used the MOPAT before and after pharmacologic and nonpharmacologic pain interventions in 100 patients admitted to a community-based hospice in a noncommunicative state and receiving palliative care for a diagnosis or condition known to cause acute pain.
Their average age was 72.6 years (range, 35-99 years); 61% were women; 92% were white; and 53% were in the active/terminal phase of dying. Other reasons for noncommunication included expressive/receptive aphasia (15%), metabolic encephalopathy (7%), stroke (6%), malignancy (5%), and delirium (5%). Pain was typically due to functional activities such as bathing and turning patients (57.3%), followed by inadequate analgesia in 31% and other reasons in 12%.
Agreement between staff and study nurses on pain ratings before and after the pain interventions was generally good on both the behavioral dimension (61.2% vs. 73.3%) and physiologic dimension (79.6% vs. 78%), said Dr. McGuire, professor of nursing at the university.
Results for internal consistency were acceptable for the behavioral dimension (alpha coefficient, 0.77 for study nurses and 0.81 for staff nurses) and for the overall scores (0.77), but not for the physiologic dimension (0.44 for study nurses; 0.63 for staff nurses). The inability to scale the severity of physiologic indicators likely contributed to the low alpha coefficients for this dimension, she said, adding in an interview that the dimension is currently being revised for the investigators’ next study.
Still, pain scores as rated by staff nurses decreased significantly after the pain interventions on the behavioral (mean, 6.3 vs. 1.7) and physiologic dimensions (mean, 1.49 vs. 0.89), indicating that "the MOPAT was sensitive to changes in pain and therefore a good measure of pain severity," Dr. McGuire said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
When surveyed on how often they encountered patients unable to communicate, 64.5% of 62 nurses said frequently; 32%, occasionally; and 3.2%, constantly.
Using a five-point scale, nurses also reported that the MOPAT was easy to use (mean score, 3.86); was easy to understand (3.90); assisted in communicating to others about the patient’s pain (3.67); and was helpful in determining whether the patient might need a pain relief intervention (3.64).
Dr. McGuire noted that the Hospice of Lancaster County (Pa.) has incorporated the MOPAT into its pain standard of care in the inpatient units and the home setting, and that it will be tested in combination with analgesic order sets in 22 different hospital inpatient units to examine pain-related outcomes such as severity and treatment choice.
"What we are aiming at in our longer-term program of research is to be able to find a simple tool that can be used to assess pain in people who can’t self-report across various settings in which palliative care is given – not just acute care or hospice," she said.
The National Institute of Nursing Research sponsored the study. Dr. McGuire and her coauthors reported no relevant financial disclosures.
NEW ORLEANS – The Multidimensional Objective Pain Assessment Tool can be used to assess and guide relief of acute pain in noncommunicative hospice patients in an inpatient setting, a study has shown.
"The MOPAT was reliable, fast, and clinically useful," Deborah McGuire, Ph.D., said at the annual assembly of the American Academy of Hospice and Palliative Medicine.
Assessing pain in patients who can not self-report their pain is a continuing clinical challenge, she observed. There are few validated assessment tools, and the limited research that is available is typically in partially cognitively impaired patients, limiting the ability to extrapolate the findings to patients who are fully cognitively impaired.
To address this gap, investigators at the University of Maryland School of Nursing in Baltimore validated the MOPAT, which consists of a four-item behavioral dimension ranked on a 3-point scale with 0 being none and 3 severe, and a three-item physiologic dimension rated as "no change from usual" or "change from usual." Both dimensions are summed for a total score of pain severity.
As part of the hospital study, staff and study nurses also used the MOPAT before and after pharmacologic and nonpharmacologic pain interventions in 100 patients admitted to a community-based hospice in a noncommunicative state and receiving palliative care for a diagnosis or condition known to cause acute pain.
Their average age was 72.6 years (range, 35-99 years); 61% were women; 92% were white; and 53% were in the active/terminal phase of dying. Other reasons for noncommunication included expressive/receptive aphasia (15%), metabolic encephalopathy (7%), stroke (6%), malignancy (5%), and delirium (5%). Pain was typically due to functional activities such as bathing and turning patients (57.3%), followed by inadequate analgesia in 31% and other reasons in 12%.
Agreement between staff and study nurses on pain ratings before and after the pain interventions was generally good on both the behavioral dimension (61.2% vs. 73.3%) and physiologic dimension (79.6% vs. 78%), said Dr. McGuire, professor of nursing at the university.
Results for internal consistency were acceptable for the behavioral dimension (alpha coefficient, 0.77 for study nurses and 0.81 for staff nurses) and for the overall scores (0.77), but not for the physiologic dimension (0.44 for study nurses; 0.63 for staff nurses). The inability to scale the severity of physiologic indicators likely contributed to the low alpha coefficients for this dimension, she said, adding in an interview that the dimension is currently being revised for the investigators’ next study.
Still, pain scores as rated by staff nurses decreased significantly after the pain interventions on the behavioral (mean, 6.3 vs. 1.7) and physiologic dimensions (mean, 1.49 vs. 0.89), indicating that "the MOPAT was sensitive to changes in pain and therefore a good measure of pain severity," Dr. McGuire said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
When surveyed on how often they encountered patients unable to communicate, 64.5% of 62 nurses said frequently; 32%, occasionally; and 3.2%, constantly.
Using a five-point scale, nurses also reported that the MOPAT was easy to use (mean score, 3.86); was easy to understand (3.90); assisted in communicating to others about the patient’s pain (3.67); and was helpful in determining whether the patient might need a pain relief intervention (3.64).
Dr. McGuire noted that the Hospice of Lancaster County (Pa.) has incorporated the MOPAT into its pain standard of care in the inpatient units and the home setting, and that it will be tested in combination with analgesic order sets in 22 different hospital inpatient units to examine pain-related outcomes such as severity and treatment choice.
"What we are aiming at in our longer-term program of research is to be able to find a simple tool that can be used to assess pain in people who can’t self-report across various settings in which palliative care is given – not just acute care or hospice," she said.
The National Institute of Nursing Research sponsored the study. Dr. McGuire and her coauthors reported no relevant financial disclosures.
AT THE AMERICAN ACADEMY OF HOSPICE AND PALLIATIVE MEDICINE ANNUAL ASSEMBLY
Major finding: Pain scores as rated by staff nurses decreased significantly after the pain interventions on the behavioral (mean, 6.3 vs. 1.7) and physiologic dimensions (mean, 1.49 vs. 0.89).
Data source: A prospective, longitudinal study in 100 inpatients receiving palliative care in a community-based hospice.
Disclosures: The National Institute of Nursing Research sponsored the study. Dr. McGuire and her coauthors reported no relevant financial disclosures.
YouTube poor source of palliative information
NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.
Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.
"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."
Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.
Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.
Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).
Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.
As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.
"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.
"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."
The authors reported having no financial disclosures.
NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.
Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.
"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."
Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.
Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.
Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).
Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.
As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.
"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.
"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."
The authors reported having no financial disclosures.
NEW ORLEANS – Just 28% of 468 videos sampled from YouTube were rated as having useful information on palliative care, hospice, or end of life, while 72% were considered poor quality.
Unfortunately, the poor information is getting much more exposure: Poor-quality videos averaged about 28,056,711 million hits, compared with only about 11,808 hits for the good-quality videos, Benjamin Getter, D.O., said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
One reason may be the sheer volume of videos and that patients are likely to use filters or broad search terms such as "palliative care" or "pain." YouTube queues up videos containing those words based on viewer count, so when view counts are low, videos get pushed back further on search results page.
"Studies have shown that whether it’s Google or YouTube, the distance you will go looking for your information decreases exponentially," he said. "The third page of Google might as well not exist."
Dr. Getter pointed out that more than 700 YouTube videos are shared on Twitter each minute and that 100 million people take some social action be it sharing, liking, or commenting on YouTube every week. Younger generations are also using YouTube videos as a source of news, "This is something we need to take advantage of," he said.
Dr. Getter and his coauthor, Dr. Wesam Aziz, both palliative medicine fellows at the University of Texas Health Science Center in San Antonio, identified the 468 YouTube videos by relevance and view count search strategies, and independently categorized them as useful, misleading, or personal experience. Videos creators fell into one of five categories: health care institutions, media/news organizations, hospices, universities, and individuals.
Video quality was "good" if the video had useful information, including relevant personal experiences, or "not good" if the video was misleading or not related to palliative care. In all, 133 videos were of good quality (28%) and 335 not-good quality (72%).
Dr. Getter acknowledged that the rating system was subjective, but said in an interview that "In 98% of cases, it was exceedingly obvious." For example, videos on nociceptive pain caused by trauma were obviously unrelated to palliative care pain, whereas the AAHPM’s "You're Sick. It's Serious" video was clearly useful and accurate.
As expected, good-quality videos were significantly more likely to come from educational or health care institutions, whereas poor quality videos were typically uploaded by independent sources and the news media.
"More outreach is needed to educate the public and news organizations about palliative care," he said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Dr. Getter suggested health care organizations also could do more, such as casting a wider net for their videos and using keywords and search terms in their content to optimize their videos for search engines, a process known as search engine optimization.
"Share, share, share; be your own advocate," he urged. "You’d be surprised at how many of these videos that were great and were uploaded by health care and hospice organizations can’t be found anywhere on their websites. To me, it just seems kind of silly to go to all the trouble producing these things and not have the exposure."
The authors reported having no financial disclosures.
Major finding: In all, 133 palliative care videos (28%) were good quality and 335 were poor quality (72%).
Data source: Retrospective analysis of 468 YouTube videos.
Disclosures: The authors reported having no financial disclosures.
Nurse-led delirium screen validated in hospitalized elderly
NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.
The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.
To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).
A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.
In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.
Thus, sensitivity was 90% and specificity 91%.
Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.
Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.
"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.
E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.
Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.
"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."
As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.
During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.
Ms. Gavinski and her coauthors reported no relevant disclosures.
NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.
The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.
To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).
A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.
In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.
Thus, sensitivity was 90% and specificity 91%.
Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.
Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.
"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.
E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.
Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.
"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."
As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.
During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.
Ms. Gavinski and her coauthors reported no relevant disclosures.
NEW ORLEANS – The Delirium Observation Screening Scale is easy, fast, and accurate when performed by a bedside nurse in elderly hospitalized patients, according to results of a validation study.
The purely observational screening tool requires no cognitive testing or additional education for nursing staff and typically takes 2-3 minutes to complete, Katie Gavinski, a medical student at the University of Iowa, Iowa City, said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
The DOSS includes 13 yes/no questions, such as whether the patient maintains attention to a conversation or action or knows which part of the day it is. A score of 15 or more is considered positive for delirium. The DOSS was developed and validated in the Netherlands but had not been validated in the United States in an elderly patient population, she said.
To accomplish this, the investigators compared results in the medical records of 54 elderly patients in a general medicine inpatient unit from twice-daily screening with the DOSS and those prospectively obtained using the 16-item, clinician-rated Delirium Rating Scale-Revised-98 (DRS-R-98).
A total of 100 delirium assessments were performed in the 54 patients, whose average age was 77 years; 40% were male.
In all, 83 tests were negative for delirium and 17 were positive. There was one false-negative test and 8 false-positive results, of which seven were in patients considered in sub-syndromal delirium based on a DRS-R-98 score of 8-14, Ms. Gavinski reported.
Thus, sensitivity was 90% and specificity 91%.
Positive DRS-R-98 screens were significantly correlated with positive DOSS screens for delirium, she said.
Senior author and colleague Dr. Michelle Weckmann, also of the University of Iowa, said that the DOSS is not designed to be used by physicians but appears to be a powerful tool in the hands of nurses.
"Routine implementation of the DOSS on hospital units has the potential to increase identification of delirium with minimal use of hospital resources, and improved identification of delirium has the potential to significantly improve patient care and outcomes," she said in an interview.
E-mail surveys from 98 adult-unit nurses revealed that 87% were confident performing the DOSS and 91% said that they could complete it in less than 3 minutes.
Only about 30% of the nurses, however, agreed or strongly agreed that the DOSS provided valuable information for the treatment of their patients or enhanced patient care, Ms. Gavinski said.
"The biggest thing nursing staff called for was additional education," she said. "They understood how to do it and that they would get a positive result for delirium, but didn’t know what to do with that result."
As a result of the study, the DOSS has been integrated into all adult units, and about 98% of patients over the age of 64 are now being screened with the DOSS at least once during their hospitalization. A delirium order set also was developed to address the question of what to do next if a screen is positive. Future research will evaluate whether delirium screening with the DOSS improves the outcomes of patients who test positive, Ms. Gavinski said.
During a discussion of the study, she noted that the 2 a.m. and 2 p.m. screening times used in the study were selected arbitrarily and that the test can be completed whenever nurses interact with their patients. Also, the DOSS does not specifically measure delirium severity, whereas the DRS-R-98 has 13 severity items and 3 diagnostic items.
Ms. Gavinski and her coauthors reported no relevant disclosures.
Major finding: The DOSS had a sensitivity of 90% and specificity of 91%.
Data source: Prospective validation study in 54 elderly hospitalized patients.
Disclosures: Ms. Gavinski and her coauthors reported no relevant disclosures.
New palliative care guidelines stress certification, diversity
NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.
The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.
Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.
This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.
"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.
In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.
The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.
Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.
She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.
The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.
"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.
The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.
"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.
The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.
During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.
"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.
"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."
The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.
NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.
The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.
Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.
This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.
"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.
In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.
The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.
Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.
She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.
The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.
"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.
The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.
"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.
The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.
During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.
"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.
"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."
The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.
NEW ORLEANS – New palliative care guidelines encourage discipline-specific certification for each of the major disciplines in a palliative care program, even for chaplaincy.
The guidelines are critical in raising the bar to guide the training of professionals and the development of programs, said Dr. Diane Meier, coleader of the National Consensus Project for Quality Palliative Care (NCP), which released the guidelines during the annual meeting of the American Academy of Hospice and Palliative Medicine.
Since the guidelines’ last revision in 2009, the Accreditation Council for Graduate Medical Education recognized hospice and palliative medicine as a subspecialty of 11 different parent boards. That paved the way for the development of hospice and palliative medicine fellowships, now an eligibility requirement for the board certification exams.
This year, the Centers for Medicare and Medicaid Services also began implementing an annual quality reporting program for hospice organizations that includes a financial incentive for hospice provider participation. Data from roughly 600 hospitals are also filed with the Center to Advance Palliative Care (CAPC), which releases a report card on access to palliative care in U.S. hospitals.
"Right now it’s too early in the field to use it for public reporting or payment, but it’s not too early to use it to be able to say, ‘Look, here are the standards, and here’s how we compare in terms of staffing ratios to peer hospitals in our part of the country, and we aren’t even close,’ " Dr. Meier, CAPC director and professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, said in an interview.
In 2011, 46% of the roughly 2.5 million deaths in the United States were under the care of one of the nation’s more than 5,000 hospices, with data suggesting that costs during the last year of life are cut by an average of $2,309 per hospice user.
The new, third edition of the Clinical Practice Guidelines for Quality Palliative Care, endorsed by some 50 organizations, emphasizes the need to deliver palliative care from the time of diagnosis, through an interdisciplinary team. Earlier editions of the guidelines were used as the basis for the National Quality Forum Framework and Preferred Practices for Quality Palliative Care, as well as the Joint Commission’s 2011 palliative care advanced certification.
Although hospice and palliative care at a 300-bed tertiary hospital will look substantially different than at a 40-bed community hospital, it must include all eight domains of care. It is not a physician and a half-time nurse doing pain consults, insists NCP coleader Betty Ferrell, Ph.D., R.N.
She observed that the social, cultural, and spiritual domains have undergone the biggest changes in the latest edition.
The social domain emphasizes the need to collaborate with patients and families to identify and capitalize on their strengths, and to use a social worker with patient population–specific skills in assessment and interventions. The cultural domain contains new content stressing the need for cultural and linguistic competence, including plain language, literacy, and delivering written materials in languages other than English. Translators also should be used for patients and families who do not speak or understand English, or for those who feel more comfortable communicating in another language.
"We really need to do a lot of this [work] because, if you look at our literature, you could say it’s kind of uni-perspective," Dr. Ferrell, a professor and research scientist at the City of Hope Medical Center in Los Angeles, acknowledged.
The spiritual domain was revised to include a definition of spirituality stressing assessment, access, and staff collaboration in attending to the spiritual, religious, and existential concerns throughout the illness trajectory.
"Chaplains may see a small minority of patients in the hospital; thus it’s important for all health care providers to address spiritual needs," she said.
The ethical and legal domain was reorganized into three sections to highlight the need for ongoing discussions about goals of care as well as greater communication and documentation of advance-care planning documents. The section also describes team competencies in the identification and resolution of ethical issues, and acknowledges the frequency and complexity of legal and regulatory issues in palliative care.
During a discussion of the guidelines, audience members said they’ve often been kept from doing the next step in care because of fear of legal reprisal. Only a dozen or so of the roughly 200 members in the audience, however, raised their hands when asked whether legal counsel had ever attended a palliative care meeting at their hospital.
"We’ve had ethics committees involved in palliative care; but we actually need more access to our legal counsel so we can feel safer and that we’re making consistent judgments," Dr. Ferrell said at the meeting, also sponsored by the Hospice and Palliative Nurses Association.
Finally, the domain previously called "Care of the imminently dying" was renamed "Care of the patient at the end of life." It highlights the need to meticulously assess and manage pain and other symptoms, to guide families about what to expect in the dying process, and to begin bereavement support before the actual death.
"Families need support, given that they have often never witnessed a death until faced with losing someone they love," she said. "The reality of death is very different from images on film and television."
The guidelines were sponsored by the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, the National Association of Social Workers, and the National Palliative Care Research Center. Dr. Meier and Dr. Ferrell reported no relevant conflicts of interest.
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