Hospice & Palliative Medicine

Have you met an oncology hospitalist yet? If you haven’t, you probably will soon.

The latest offshoot of hospital medicine aims to take all the strengths of the hospitalist movement – increased efficiency and improved quality and safety – and apply them to inpatient cancer care.

While there is no typical oncology-hospitalist program, most manage the complications of a patient’s cancer and treatment, as well as providing some type of end-of-life services. Oncology hospitalists may be oncologists with an interest in taking care of hospitalized patients. Or they could be hospitalists trained in internal or family medicine, who have an interest in caring for cancer patients.

"People are very interested in this, and we really want to grow it," said Dr. Maria-Claudia Campagna, an oncology-hospitalist at the University of Texas MD Anderson Cancer Center in Houston.

Dr. Campagna is part of a nine-physician oncology-hospitalist program at MD Anderson. The program was launched in 2006 with just one hospitalist, but has grown to nine hospitalists over the last several years. And the program is in the process of recruiting three more physicians.

They are also piloting an observation unit geared toward oncology patients, she said.

Much like in the early days of hospital medicine, Dr. Campagna said the program initially got pushback from oncologists who didn’t want to give up care of their patients in the hospital. But over time, the hospitalists have proven their competence and oncologists have gotten even busier with their outpatient practices.

Courtesy Dr. Stephen Schleicher

"They know we take good care of their patients, so ultimately they trust our criteria. And when we don’t know, we tell them," Dr. Campagna said. "So we have a very symbiotic relationship."

The experience at MD Anderson is being replicated at cancer centers and academic medical centers around the country. Even some community hospitals are exploring the idea.

The reason is simple, said Dr. Eddy Chen, an oncology hospitalist at Dana-Farber/Brigham and Women’s Cancer Center in Boston. The combination of a coming shortage of oncologists combined with an expected surge in cancer patients among aging baby boomers means that virtually every hospital will see a marked increase in cancer patients over the next several years.

"In the future, there are going to be a lot more patients with cancer who are going to be coming into the hospital," Dr. Chen said. "And who is going to take care of these patients?"

But I’m not an oncologist ...

At Dana-Farber/Brigham and Women’s, they have three oncology hospitalists, including Dr. Chen. Along with the regular cadre of oncologists, they manage all of the hospitalized cancer patients. What makes hospitalist management different from that of the oncologists, who are treating both inpatients and outpatients, is the focus on quality improvement, patient safety, and research, said Dr. Chen.

Dr. Chen, who is trained as an oncologist, said hospitalists don’t need to be oncologists to do this job. But as the field develops, there are likely to be some training or prerequisites that will develop. For now, Dr. Chen said hospitalists need to have an interest in treating complex patients and be willing to develop a deeper understanding of the principles of cancer medicine.

"We are now at a point in the road of this endeavor where best practices, and understanding these issues, can be further defined," Dr. Chen said.

As Dr. Chen proves, oncology hospitalists can be oncologists or traditional hospitalists trained in internal medicine or family medicine. But they must all be prepared to handle complex patients and take on end-of-life discussions.

At Memorial Sloan-Kettering Cancer Center in New York, where the oncology-hospitalist team works mainly with GI oncology and lymphoma patients, they treat patients with very advanced disease, many of whom are in the last 6 months of life.

"We’ve attained a lot of experience and expertise in end-of-life care, but it’s all been on-the-job training," said Dr. Barbara C. Egan, chief of the hospital medicine service at Sloan-Kettering.

Because of the heavy focus on end-of-life care, Dr. Egan and some of the other hospitalists in her group were recently board certified in hospice and palliative medicine based in part on their clinical experience working with cancer patients.

Emotional days

The work is very different from a general medicine hospitalist service. For oncology hospitalists, all of the patients have multisystem organ disease and also typically have complicated psychosocial dynamics end-of-life care. The result is a time-consuming, emotionally charged day that isn’t accurately measured by RVUs (relative value units) or the number of encounters per day, Dr. Egan said.

"It’s very different to round on a 25-year-old who’s dying of colon cancer, than in a general medicine hospital where you might have several patients on the service who are there for single issue, uncomplicated soft rule-out MI." she said. "It’s definitely very emotionally draining on the physicians."

To try to prevent burnout among their physicians, Sloan-Kettering’s program consists of seven daytime hospitalists who work a typical 2-week on/2-week off schedule. The other 10 hospitalists are dedicated nocturnalists. The model has resulted in virtually no turnover among the daytime hospitalists. The nocturnal group has high turnover, which is typical of most night-shift work. At this point, there’s no definitive count of the number of oncology hospitalists working in the United States today. But what is clear, is that the small niche is growing.

Dr. A. Charlotta Weaver, medical director of oncology hospitalists at Northwestern Memorial Hospital in Chicago, epitomizes the appeal for some young physicians.

Dr. Weaver graduated from residency in 2008, a year after Northwestern launched its oncology-hospitalist program. She had been considering a fellowship in hematology/oncology when she heard about the new program. "This little light went off in my head that that’s what I wanted to do," she said.

Initially, she thought about working as an oncology hospitalist for a few years as a bridge to fellowship, but ultimately decided to stay on with the program. The appeals, she said, was a combination of the hospitalist schedule and taking care of hematology/oncology patients.

"I think of it as real medicine. They are really sick," Dr. Weaver said. "There is something legitimately wrong with them and I can help; whereas in general medicine, you don’t always have that sense."

[email protected]

On Twitter @maryellenny

Have you met an oncology hospitalist yet? If you haven’t, you probably will soon.

The latest offshoot of hospital medicine aims to take all the strengths of the hospitalist movement – increased efficiency and improved quality and safety – and apply them to inpatient cancer care.

While there is no typical oncology-hospitalist program, most manage the complications of a patient’s cancer and treatment, as well as providing some type of end-of-life services. Oncology hospitalists may be oncologists with an interest in taking care of hospitalized patients. Or they could be hospitalists trained in internal or family medicine, who have an interest in caring for cancer patients.

"People are very interested in this, and we really want to grow it," said Dr. Maria-Claudia Campagna, an oncology-hospitalist at the University of Texas MD Anderson Cancer Center in Houston.

Dr. Campagna is part of a nine-physician oncology-hospitalist program at MD Anderson. The program was launched in 2006 with just one hospitalist, but has grown to nine hospitalists over the last several years. And the program is in the process of recruiting three more physicians.

They are also piloting an observation unit geared toward oncology patients, she said.

Much like in the early days of hospital medicine, Dr. Campagna said the program initially got pushback from oncologists who didn’t want to give up care of their patients in the hospital. But over time, the hospitalists have proven their competence and oncologists have gotten even busier with their outpatient practices.

Courtesy Dr. Stephen Schleicher

"They know we take good care of their patients, so ultimately they trust our criteria. And when we don’t know, we tell them," Dr. Campagna said. "So we have a very symbiotic relationship."

The experience at MD Anderson is being replicated at cancer centers and academic medical centers around the country. Even some community hospitals are exploring the idea.

The reason is simple, said Dr. Eddy Chen, an oncology hospitalist at Dana-Farber/Brigham and Women’s Cancer Center in Boston. The combination of a coming shortage of oncologists combined with an expected surge in cancer patients among aging baby boomers means that virtually every hospital will see a marked increase in cancer patients over the next several years.

"In the future, there are going to be a lot more patients with cancer who are going to be coming into the hospital," Dr. Chen said. "And who is going to take care of these patients?"

But I’m not an oncologist ...

At Dana-Farber/Brigham and Women’s, they have three oncology hospitalists, including Dr. Chen. Along with the regular cadre of oncologists, they manage all of the hospitalized cancer patients. What makes hospitalist management different from that of the oncologists, who are treating both inpatients and outpatients, is the focus on quality improvement, patient safety, and research, said Dr. Chen.

Dr. Chen, who is trained as an oncologist, said hospitalists don’t need to be oncologists to do this job. But as the field develops, there are likely to be some training or prerequisites that will develop. For now, Dr. Chen said hospitalists need to have an interest in treating complex patients and be willing to develop a deeper understanding of the principles of cancer medicine.

"We are now at a point in the road of this endeavor where best practices, and understanding these issues, can be further defined," Dr. Chen said.

As Dr. Chen proves, oncology hospitalists can be oncologists or traditional hospitalists trained in internal medicine or family medicine. But they must all be prepared to handle complex patients and take on end-of-life discussions.

At Memorial Sloan-Kettering Cancer Center in New York, where the oncology-hospitalist team works mainly with GI oncology and lymphoma patients, they treat patients with very advanced disease, many of whom are in the last 6 months of life.

"We’ve attained a lot of experience and expertise in end-of-life care, but it’s all been on-the-job training," said Dr. Barbara C. Egan, chief of the hospital medicine service at Sloan-Kettering.

Because of the heavy focus on end-of-life care, Dr. Egan and some of the other hospitalists in her group were recently board certified in hospice and palliative medicine based in part on their clinical experience working with cancer patients.

Emotional days

The work is very different from a general medicine hospitalist service. For oncology hospitalists, all of the patients have multisystem organ disease and also typically have complicated psychosocial dynamics end-of-life care. The result is a time-consuming, emotionally charged day that isn’t accurately measured by RVUs (relative value units) or the number of encounters per day, Dr. Egan said.

"It’s very different to round on a 25-year-old who’s dying of colon cancer, than in a general medicine hospital where you might have several patients on the service who are there for single issue, uncomplicated soft rule-out MI." she said. "It’s definitely very emotionally draining on the physicians."

To try to prevent burnout among their physicians, Sloan-Kettering’s program consists of seven daytime hospitalists who work a typical 2-week on/2-week off schedule. The other 10 hospitalists are dedicated nocturnalists. The model has resulted in virtually no turnover among the daytime hospitalists. The nocturnal group has high turnover, which is typical of most night-shift work. At this point, there’s no definitive count of the number of oncology hospitalists working in the United States today. But what is clear, is that the small niche is growing.

Dr. A. Charlotta Weaver, medical director of oncology hospitalists at Northwestern Memorial Hospital in Chicago, epitomizes the appeal for some young physicians.

Dr. Weaver graduated from residency in 2008, a year after Northwestern launched its oncology-hospitalist program. She had been considering a fellowship in hematology/oncology when she heard about the new program. "This little light went off in my head that that’s what I wanted to do," she said.

Initially, she thought about working as an oncology hospitalist for a few years as a bridge to fellowship, but ultimately decided to stay on with the program. The appeals, she said, was a combination of the hospitalist schedule and taking care of hematology/oncology patients.

"I think of it as real medicine. They are really sick," Dr. Weaver said. "There is something legitimately wrong with them and I can help; whereas in general medicine, you don’t always have that sense."

[email protected]

On Twitter @maryellenny

Have you met an oncology hospitalist yet? If you haven’t, you probably will soon.

The latest offshoot of hospital medicine aims to take all the strengths of the hospitalist movement – increased efficiency and improved quality and safety – and apply them to inpatient cancer care.

While there is no typical oncology-hospitalist program, most manage the complications of a patient’s cancer and treatment, as well as providing some type of end-of-life services. Oncology hospitalists may be oncologists with an interest in taking care of hospitalized patients. Or they could be hospitalists trained in internal or family medicine, who have an interest in caring for cancer patients.

"People are very interested in this, and we really want to grow it," said Dr. Maria-Claudia Campagna, an oncology-hospitalist at the University of Texas MD Anderson Cancer Center in Houston.

Dr. Campagna is part of a nine-physician oncology-hospitalist program at MD Anderson. The program was launched in 2006 with just one hospitalist, but has grown to nine hospitalists over the last several years. And the program is in the process of recruiting three more physicians.

They are also piloting an observation unit geared toward oncology patients, she said.

Much like in the early days of hospital medicine, Dr. Campagna said the program initially got pushback from oncologists who didn’t want to give up care of their patients in the hospital. But over time, the hospitalists have proven their competence and oncologists have gotten even busier with their outpatient practices.

Courtesy Dr. Stephen Schleicher

"They know we take good care of their patients, so ultimately they trust our criteria. And when we don’t know, we tell them," Dr. Campagna said. "So we have a very symbiotic relationship."

The experience at MD Anderson is being replicated at cancer centers and academic medical centers around the country. Even some community hospitals are exploring the idea.

The reason is simple, said Dr. Eddy Chen, an oncology hospitalist at Dana-Farber/Brigham and Women’s Cancer Center in Boston. The combination of a coming shortage of oncologists combined with an expected surge in cancer patients among aging baby boomers means that virtually every hospital will see a marked increase in cancer patients over the next several years.

"In the future, there are going to be a lot more patients with cancer who are going to be coming into the hospital," Dr. Chen said. "And who is going to take care of these patients?"

But I’m not an oncologist ...

At Dana-Farber/Brigham and Women’s, they have three oncology hospitalists, including Dr. Chen. Along with the regular cadre of oncologists, they manage all of the hospitalized cancer patients. What makes hospitalist management different from that of the oncologists, who are treating both inpatients and outpatients, is the focus on quality improvement, patient safety, and research, said Dr. Chen.

Dr. Chen, who is trained as an oncologist, said hospitalists don’t need to be oncologists to do this job. But as the field develops, there are likely to be some training or prerequisites that will develop. For now, Dr. Chen said hospitalists need to have an interest in treating complex patients and be willing to develop a deeper understanding of the principles of cancer medicine.

"We are now at a point in the road of this endeavor where best practices, and understanding these issues, can be further defined," Dr. Chen said.

As Dr. Chen proves, oncology hospitalists can be oncologists or traditional hospitalists trained in internal medicine or family medicine. But they must all be prepared to handle complex patients and take on end-of-life discussions.

At Memorial Sloan-Kettering Cancer Center in New York, where the oncology-hospitalist team works mainly with GI oncology and lymphoma patients, they treat patients with very advanced disease, many of whom are in the last 6 months of life.

"We’ve attained a lot of experience and expertise in end-of-life care, but it’s all been on-the-job training," said Dr. Barbara C. Egan, chief of the hospital medicine service at Sloan-Kettering.

Because of the heavy focus on end-of-life care, Dr. Egan and some of the other hospitalists in her group were recently board certified in hospice and palliative medicine based in part on their clinical experience working with cancer patients.

Emotional days

The work is very different from a general medicine hospitalist service. For oncology hospitalists, all of the patients have multisystem organ disease and also typically have complicated psychosocial dynamics end-of-life care. The result is a time-consuming, emotionally charged day that isn’t accurately measured by RVUs (relative value units) or the number of encounters per day, Dr. Egan said.

"It’s very different to round on a 25-year-old who’s dying of colon cancer, than in a general medicine hospital where you might have several patients on the service who are there for single issue, uncomplicated soft rule-out MI." she said. "It’s definitely very emotionally draining on the physicians."

To try to prevent burnout among their physicians, Sloan-Kettering’s program consists of seven daytime hospitalists who work a typical 2-week on/2-week off schedule. The other 10 hospitalists are dedicated nocturnalists. The model has resulted in virtually no turnover among the daytime hospitalists. The nocturnal group has high turnover, which is typical of most night-shift work. At this point, there’s no definitive count of the number of oncology hospitalists working in the United States today. But what is clear, is that the small niche is growing.

Dr. A. Charlotta Weaver, medical director of oncology hospitalists at Northwestern Memorial Hospital in Chicago, epitomizes the appeal for some young physicians.

Dr. Weaver graduated from residency in 2008, a year after Northwestern launched its oncology-hospitalist program. She had been considering a fellowship in hematology/oncology when she heard about the new program. "This little light went off in my head that that’s what I wanted to do," she said.

Initially, she thought about working as an oncology hospitalist for a few years as a bridge to fellowship, but ultimately decided to stay on with the program. The appeals, she said, was a combination of the hospitalist schedule and taking care of hematology/oncology patients.

"I think of it as real medicine. They are really sick," Dr. Weaver said. "There is something legitimately wrong with them and I can help; whereas in general medicine, you don’t always have that sense."

[email protected]

On Twitter @maryellenny

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

DALLAS – Jet-injected lidocaine is superior to vapocoolant spray in reducing venipuncture pain in children under 7 years of age, according to a randomized, double-blind clinical trial.

This form of needle-free local anesthesia, administered through what is popularly known as the J-Tip syringe, has been shown previously to decrease venipuncture pain in adults and older children. But data regarding the effectiveness of the J-Tip in young children has been scanty until now, Dr. Maren M. Lunoe noted at the annual meeting of the Society for Academic Emergency Medicine.

She presented the findings of a randomized, sham-controlled, double-blind clinical trial involving 205 children aged 1-6 years who presented for venipuncture. Ninety percent had undergone the procedure before.

The J-Tip device utilizes a cartridge of compressed carbon dioxide to drive buffered lidocaine into the skin. However, it does so with a loud "pop," which is why the study included a control arm featuring a sham J-Tip syringe with the compressed gas but no lidocaine, explained Dr. Lunoe of the Medical College of Wisconsin, Milwaukee.

Participants were randomized 2:1:1 to the J-Tip syringe deployed roughly 30 seconds prior to venipuncture; to a refrigerated vapocoolant spray, also applied immediately prior to venipuncture, which has been usual care for a blood draw at Children’s Hospital of Wisconsin; or to a second control group who received vapocoolant spray and a sham J-Tip.

The primary endpoint was the FLACC score at venipuncture as assessed by two blinded physicians viewing videotapes of every procedure. The FLACC (Face, Legs, Activity, Cry, and Consolability) scale is a validated pain assessment tool scored 0-10.

The median FLACC score while the young children were waiting for the nurse was 2.0. The score jumped by about 2 points in all three groups when the child saw the device. It climbed by another 5.5 points from that point to the actual venipuncture in controls who got vapocoolant spray only, and by 2.5 points in those who got vapocoolant spray plus a sham J-Tip. These increases in FLACC pain score at venipuncture were statistically significant and clinically meaningful. In contrast, patients who received needle-free lidocaine through a loaded J-Tip syringe did not experience a significant increase in FLACC scores at venipuncture.

Forty-five percent of patients in the J-Tip group had no or only mild pain at venipuncture as defined by a FLACC score of 0-3. This was the case in only 23% of the vapocoolant spray–only group and in 30% of controls who got vapocoolant spray and a sham J-Tip.

There were no between-group differences in adverse events, all of which were minor, consisting mostly of mild bruising.

Asked why the study didn’t include a comparison arm pretreated with EMLA cream, Dr. Lunoe said that topical agent takes 30 minutes to take effect, making it unattractive for use in an emergency department or busy clinic.

National Medical Products and Gebauer, which market the J-Tip syringe and the vapocoolant spray, respectively, provided those supplies for the study but had no further involvement. Dr. Lunoe reported no financial conflicts with regard to the investigation.

[email protected]

DALLAS – Jet-injected lidocaine is superior to vapocoolant spray in reducing venipuncture pain in children under 7 years of age, according to a randomized, double-blind clinical trial.

This form of needle-free local anesthesia, administered through what is popularly known as the J-Tip syringe, has been shown previously to decrease venipuncture pain in adults and older children. But data regarding the effectiveness of the J-Tip in young children has been scanty until now, Dr. Maren M. Lunoe noted at the annual meeting of the Society for Academic Emergency Medicine.

She presented the findings of a randomized, sham-controlled, double-blind clinical trial involving 205 children aged 1-6 years who presented for venipuncture. Ninety percent had undergone the procedure before.

The J-Tip device utilizes a cartridge of compressed carbon dioxide to drive buffered lidocaine into the skin. However, it does so with a loud "pop," which is why the study included a control arm featuring a sham J-Tip syringe with the compressed gas but no lidocaine, explained Dr. Lunoe of the Medical College of Wisconsin, Milwaukee.

Participants were randomized 2:1:1 to the J-Tip syringe deployed roughly 30 seconds prior to venipuncture; to a refrigerated vapocoolant spray, also applied immediately prior to venipuncture, which has been usual care for a blood draw at Children’s Hospital of Wisconsin; or to a second control group who received vapocoolant spray and a sham J-Tip.

The primary endpoint was the FLACC score at venipuncture as assessed by two blinded physicians viewing videotapes of every procedure. The FLACC (Face, Legs, Activity, Cry, and Consolability) scale is a validated pain assessment tool scored 0-10.

The median FLACC score while the young children were waiting for the nurse was 2.0. The score jumped by about 2 points in all three groups when the child saw the device. It climbed by another 5.5 points from that point to the actual venipuncture in controls who got vapocoolant spray only, and by 2.5 points in those who got vapocoolant spray plus a sham J-Tip. These increases in FLACC pain score at venipuncture were statistically significant and clinically meaningful. In contrast, patients who received needle-free lidocaine through a loaded J-Tip syringe did not experience a significant increase in FLACC scores at venipuncture.

Forty-five percent of patients in the J-Tip group had no or only mild pain at venipuncture as defined by a FLACC score of 0-3. This was the case in only 23% of the vapocoolant spray–only group and in 30% of controls who got vapocoolant spray and a sham J-Tip.

There were no between-group differences in adverse events, all of which were minor, consisting mostly of mild bruising.

Asked why the study didn’t include a comparison arm pretreated with EMLA cream, Dr. Lunoe said that topical agent takes 30 minutes to take effect, making it unattractive for use in an emergency department or busy clinic.

National Medical Products and Gebauer, which market the J-Tip syringe and the vapocoolant spray, respectively, provided those supplies for the study but had no further involvement. Dr. Lunoe reported no financial conflicts with regard to the investigation.

[email protected]

DALLAS – Jet-injected lidocaine is superior to vapocoolant spray in reducing venipuncture pain in children under 7 years of age, according to a randomized, double-blind clinical trial.

This form of needle-free local anesthesia, administered through what is popularly known as the J-Tip syringe, has been shown previously to decrease venipuncture pain in adults and older children. But data regarding the effectiveness of the J-Tip in young children has been scanty until now, Dr. Maren M. Lunoe noted at the annual meeting of the Society for Academic Emergency Medicine.

She presented the findings of a randomized, sham-controlled, double-blind clinical trial involving 205 children aged 1-6 years who presented for venipuncture. Ninety percent had undergone the procedure before.

The J-Tip device utilizes a cartridge of compressed carbon dioxide to drive buffered lidocaine into the skin. However, it does so with a loud "pop," which is why the study included a control arm featuring a sham J-Tip syringe with the compressed gas but no lidocaine, explained Dr. Lunoe of the Medical College of Wisconsin, Milwaukee.

Participants were randomized 2:1:1 to the J-Tip syringe deployed roughly 30 seconds prior to venipuncture; to a refrigerated vapocoolant spray, also applied immediately prior to venipuncture, which has been usual care for a blood draw at Children’s Hospital of Wisconsin; or to a second control group who received vapocoolant spray and a sham J-Tip.

The primary endpoint was the FLACC score at venipuncture as assessed by two blinded physicians viewing videotapes of every procedure. The FLACC (Face, Legs, Activity, Cry, and Consolability) scale is a validated pain assessment tool scored 0-10.

The median FLACC score while the young children were waiting for the nurse was 2.0. The score jumped by about 2 points in all three groups when the child saw the device. It climbed by another 5.5 points from that point to the actual venipuncture in controls who got vapocoolant spray only, and by 2.5 points in those who got vapocoolant spray plus a sham J-Tip. These increases in FLACC pain score at venipuncture were statistically significant and clinically meaningful. In contrast, patients who received needle-free lidocaine through a loaded J-Tip syringe did not experience a significant increase in FLACC scores at venipuncture.

Forty-five percent of patients in the J-Tip group had no or only mild pain at venipuncture as defined by a FLACC score of 0-3. This was the case in only 23% of the vapocoolant spray–only group and in 30% of controls who got vapocoolant spray and a sham J-Tip.

There were no between-group differences in adverse events, all of which were minor, consisting mostly of mild bruising.

Asked why the study didn’t include a comparison arm pretreated with EMLA cream, Dr. Lunoe said that topical agent takes 30 minutes to take effect, making it unattractive for use in an emergency department or busy clinic.

National Medical Products and Gebauer, which market the J-Tip syringe and the vapocoolant spray, respectively, provided those supplies for the study but had no further involvement. Dr. Lunoe reported no financial conflicts with regard to the investigation.

[email protected]

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which physicians order palliative care consults in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, heart failure, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement screening tools on one unit at a time, or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day, leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at http://www.ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which physicians order palliative care consults in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, heart failure, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement screening tools on one unit at a time, or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day, leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at http://www.ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which physicians order palliative care consults in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, heart failure, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement screening tools on one unit at a time, or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day, leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at http://www.ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

CHICAGO – Early palliative care delivered almost exclusively by telephone improved survival among patients with advanced cancer in the ENABLE III study.

After a median follow-up of a little more than 1 year, 46% of patients receiving palliative care from the time of cancer diagnosis and 54% of those with delayed palliative care had died.

Overall median survival was 18.3 months for the immediate group and 11.9 months for the delayed group (P = .17).

In preplanned analyses, the risk of death at 1 year was significantly lower in the immediate group (hazard ratio 0.72; P = .003), with a catch-up effect thereafter, Marie Bakitas, DNSc, reported at the annual meeting of the American Society of Clinical Oncology.

"Enhanced medical care, reduced aggressive care and chemotherapy use, longer access to hospice, and biologic impacts of improved quality of life have all been proposed as mechanisms to explain this survival advantage," Dr. Bakitas said. "However, at the present time, we do not have the data to support a particular mechanism and we are actively exploring this question through secondary analyses."

ENABLE (Educate, Nurture, Advise, Before Life Ends) III is the first study to examine the timing of early palliative care, but not the first to identify a survival advantage.

A recent study (N. Engl. J. Med. 2010:363:733-42) found that patients with metastatic non–small cell lung cancer (NSCLC) who received palliative care at the time of randomization lived a significant 2.7 months longer than did those receiving standard oncologic care, despite receiving significantly less aggressive end-of-life care (33% vs. 54%).

In ENABLE III, 207 patients with advanced cancer, and their caregivers, were randomized as a dyad to begin usual cancer care plus the intervention at the time of diagnosis (immediate group) or usual care alone for 3 months followed by the intervention (delayed group).

The intervention consisted of a traditional outpatient palliative care consult and six weekly structured telephone calls with a nurse coach using a guidebook that covers such topics as problem solving, symptom management, communication, and advanced care planning, explained Dr. Bakitas, the Marie O’Koren Endowed Chair and Professor, School of Nursing, and associate director of the Center for Palliative and Supportive Care, University of Alabama, Birmingham.

Usual care included the clinical consult, but not the telephone intervention.

The participants’ mean age was 64 years, half were male, 60% lived in a rural area, and 65% were married or living with a partner. Lung cancer was the most common diagnosis at 42%.

At baseline, 75% of patients were receiving chemotherapy, 19% were undergoing radiation, and 43% had an advanced directive completed at diagnosis.

Unlike the group’s prior trial comparing palliative care to usual care at 3 months, immediate versus delayed palliative care did not lead to significant improvements in quality of life on the Functional Assessment of Chronic Illness Therapy-Palliative care scale (129.9 vs. 127.2; P = .34), mood on the Center for Epidemiologic Studies Depression scale (11.2 vs. 10.8; P = .33), or symptom impact on the Quality of Life at the End of Life symptom impact subscale (11.4 vs. 12.2; P = .09).

One plausible reason for the findings is that there may not have been enough care differences between the two groups, with 40% of the delayed group receiving their first palliative care contact an average of 30 days before they were scheduled to do so on day 84, Dr. Bakitas said.

Second, difficulties in accrual and decreased study power may have made it difficult to pick up between-group differences on the subjective instruments, resulting in a type 2 error.

"A 3-month delay is still very early," Dr. Bakitas said.

She noted that early intervention allowed the palliative care team to have contact with patients for 1 year on average (range 240-493 days), compared with a median of 41-90 days from referral to death reported for outpatient clinics in a national survey of 142 National Cancer Institute and non-NCI cancer centers (JAMA 2010;303:1054-61).

Resource and chemotherapy use in ENABLE III was also comparable in both groups. Decedents in the immediate and delayed groups spent a median of 5 and 6 days, respectively, in hospital in the 7-9 months preceding death, while 8% and 5% received chemotherapy in the last 2 weeks of life.

This compares favorably with a national average of more than 8 hospital days in the last 6 months of life observed in the 2014 Dartmouth Atlas of Health Care, and a chemotherapy rate of 17.5% reported in the previously noted NSCLC study, Dr. Bakitas said.

She called for more studies of early palliative care to determine the optimal timing, personnel, essential elements, and mechanisms of improved survival.

"While the benefits of these approaches have been demonstrated when provided early after a cancer diagnosis, in practice these potentially beneficial palliative care services are often provided very late, sometimes hours or weeks before death," Dr. Bakitas said. "This trend is likely to continue in the absence of clear direction on the very pragmatic questions of who, what, and when."

The study was funded by National Institute for Nursing Research. Dr. Bakitas reported having no relevant disclosures.

Palliative care support buoys caregivers of advanced cancer patients

Providing early palliative care support to caregivers of advanced cancer patients improves their quality of life, depression, and stress burden, the ENABLE III study found.

"Similar to patients, waiting to provide these caregiver services until patients are in their last weeks to days of life may not adequately address the distress that they experience," Nick Dionne-Odom, Ph.D., RN, said at the meeting.

Caregivers for the 13 million cancer patients in the United States living with advanced disease can spend up to 8 hours per day providing assistance in activities that include symptom management, emotional and spiritual support, meal preparation, arranging medical appointments, and transportation.

The combination of this burden and witnessing someone close to you struggle with illness can cause psychological distress equal to or sometimes greater than that experienced by the patient, said Dr. Dionne-Odom, a postdoctoral fellow at the University of Alabama at Birmingham.

In ENABLE III, 122 caregivers were randomized at the time of the patient’s cancer diagnosis or 12 weeks later to a palliative care intervention that consisted of three weekly structured educational telephone calls from an advanced practice nurse coach, monthly check-in calls to address new or ongoing issues, and a bereavement call for caregivers whose loved ones died.

Caregivers were not restricted to family members, but could include close friends and even neighbors. Their mean age was 60 years, 79% were female, 75% were spouses, and all had at least a high school education.

At 12 weeks from the start of the intervention, caregivers in the immediate versus delayed group had significantly better quality of life on the Caregiver Quality of Life Index–Cancer scale (mean 50.2 vs. 56.1; P = .02) and less depressive symptoms on the Center for Epidemiologic Studies Depression (CESD) scale (10.2 vs. 16.6; P = .0006), Dr. Dionne-Odom said. Notably, the delayed group surpassed the clinical cutoff for depression of 16 on the CESD scale, he added.

The intervention did not appear to change the perception among caregivers of what was demanded of them by the patient or their objective burden, though there was a trend among the immediate group for improved caregiver stress burden on the Montgomery Borgatta Caregiver Burden Scale (13.2 vs. 13.8; P = .10).

There was no significant difference between groups in depression or grief scores for caregivers of decedents. A difference may have been detected with a larger sample size, he said, adding that prior studies have shown that reducing caregiver stress before patients’ death is associated with better bereavement adjustment.

As for why caregivers appear to benefit more than the patients from the parallel palliative care interventions, Dr. Bakitas said in an interview it may be the timing of the assessments, adding that other studies have shown an impact of palliative care at 4 months, but not at 3 months.

[email protected]

CHICAGO – Early palliative care delivered almost exclusively by telephone improved survival among patients with advanced cancer in the ENABLE III study.

After a median follow-up of a little more than 1 year, 46% of patients receiving palliative care from the time of cancer diagnosis and 54% of those with delayed palliative care had died.

Overall median survival was 18.3 months for the immediate group and 11.9 months for the delayed group (P = .17).

In preplanned analyses, the risk of death at 1 year was significantly lower in the immediate group (hazard ratio 0.72; P = .003), with a catch-up effect thereafter, Marie Bakitas, DNSc, reported at the annual meeting of the American Society of Clinical Oncology.

"Enhanced medical care, reduced aggressive care and chemotherapy use, longer access to hospice, and biologic impacts of improved quality of life have all been proposed as mechanisms to explain this survival advantage," Dr. Bakitas said. "However, at the present time, we do not have the data to support a particular mechanism and we are actively exploring this question through secondary analyses."

ENABLE (Educate, Nurture, Advise, Before Life Ends) III is the first study to examine the timing of early palliative care, but not the first to identify a survival advantage.

A recent study (N. Engl. J. Med. 2010:363:733-42) found that patients with metastatic non–small cell lung cancer (NSCLC) who received palliative care at the time of randomization lived a significant 2.7 months longer than did those receiving standard oncologic care, despite receiving significantly less aggressive end-of-life care (33% vs. 54%).

In ENABLE III, 207 patients with advanced cancer, and their caregivers, were randomized as a dyad to begin usual cancer care plus the intervention at the time of diagnosis (immediate group) or usual care alone for 3 months followed by the intervention (delayed group).

The intervention consisted of a traditional outpatient palliative care consult and six weekly structured telephone calls with a nurse coach using a guidebook that covers such topics as problem solving, symptom management, communication, and advanced care planning, explained Dr. Bakitas, the Marie O’Koren Endowed Chair and Professor, School of Nursing, and associate director of the Center for Palliative and Supportive Care, University of Alabama, Birmingham.

Usual care included the clinical consult, but not the telephone intervention.

The participants’ mean age was 64 years, half were male, 60% lived in a rural area, and 65% were married or living with a partner. Lung cancer was the most common diagnosis at 42%.

At baseline, 75% of patients were receiving chemotherapy, 19% were undergoing radiation, and 43% had an advanced directive completed at diagnosis.

Unlike the group’s prior trial comparing palliative care to usual care at 3 months, immediate versus delayed palliative care did not lead to significant improvements in quality of life on the Functional Assessment of Chronic Illness Therapy-Palliative care scale (129.9 vs. 127.2; P = .34), mood on the Center for Epidemiologic Studies Depression scale (11.2 vs. 10.8; P = .33), or symptom impact on the Quality of Life at the End of Life symptom impact subscale (11.4 vs. 12.2; P = .09).

One plausible reason for the findings is that there may not have been enough care differences between the two groups, with 40% of the delayed group receiving their first palliative care contact an average of 30 days before they were scheduled to do so on day 84, Dr. Bakitas said.

Second, difficulties in accrual and decreased study power may have made it difficult to pick up between-group differences on the subjective instruments, resulting in a type 2 error.

"A 3-month delay is still very early," Dr. Bakitas said.

She noted that early intervention allowed the palliative care team to have contact with patients for 1 year on average (range 240-493 days), compared with a median of 41-90 days from referral to death reported for outpatient clinics in a national survey of 142 National Cancer Institute and non-NCI cancer centers (JAMA 2010;303:1054-61).

Resource and chemotherapy use in ENABLE III was also comparable in both groups. Decedents in the immediate and delayed groups spent a median of 5 and 6 days, respectively, in hospital in the 7-9 months preceding death, while 8% and 5% received chemotherapy in the last 2 weeks of life.

This compares favorably with a national average of more than 8 hospital days in the last 6 months of life observed in the 2014 Dartmouth Atlas of Health Care, and a chemotherapy rate of 17.5% reported in the previously noted NSCLC study, Dr. Bakitas said.

She called for more studies of early palliative care to determine the optimal timing, personnel, essential elements, and mechanisms of improved survival.

"While the benefits of these approaches have been demonstrated when provided early after a cancer diagnosis, in practice these potentially beneficial palliative care services are often provided very late, sometimes hours or weeks before death," Dr. Bakitas said. "This trend is likely to continue in the absence of clear direction on the very pragmatic questions of who, what, and when."

The study was funded by National Institute for Nursing Research. Dr. Bakitas reported having no relevant disclosures.

Palliative care support buoys caregivers of advanced cancer patients

Providing early palliative care support to caregivers of advanced cancer patients improves their quality of life, depression, and stress burden, the ENABLE III study found.

"Similar to patients, waiting to provide these caregiver services until patients are in their last weeks to days of life may not adequately address the distress that they experience," Nick Dionne-Odom, Ph.D., RN, said at the meeting.

Caregivers for the 13 million cancer patients in the United States living with advanced disease can spend up to 8 hours per day providing assistance in activities that include symptom management, emotional and spiritual support, meal preparation, arranging medical appointments, and transportation.

The combination of this burden and witnessing someone close to you struggle with illness can cause psychological distress equal to or sometimes greater than that experienced by the patient, said Dr. Dionne-Odom, a postdoctoral fellow at the University of Alabama at Birmingham.

In ENABLE III, 122 caregivers were randomized at the time of the patient’s cancer diagnosis or 12 weeks later to a palliative care intervention that consisted of three weekly structured educational telephone calls from an advanced practice nurse coach, monthly check-in calls to address new or ongoing issues, and a bereavement call for caregivers whose loved ones died.

Caregivers were not restricted to family members, but could include close friends and even neighbors. Their mean age was 60 years, 79% were female, 75% were spouses, and all had at least a high school education.

At 12 weeks from the start of the intervention, caregivers in the immediate versus delayed group had significantly better quality of life on the Caregiver Quality of Life Index–Cancer scale (mean 50.2 vs. 56.1; P = .02) and less depressive symptoms on the Center for Epidemiologic Studies Depression (CESD) scale (10.2 vs. 16.6; P = .0006), Dr. Dionne-Odom said. Notably, the delayed group surpassed the clinical cutoff for depression of 16 on the CESD scale, he added.

The intervention did not appear to change the perception among caregivers of what was demanded of them by the patient or their objective burden, though there was a trend among the immediate group for improved caregiver stress burden on the Montgomery Borgatta Caregiver Burden Scale (13.2 vs. 13.8; P = .10).

There was no significant difference between groups in depression or grief scores for caregivers of decedents. A difference may have been detected with a larger sample size, he said, adding that prior studies have shown that reducing caregiver stress before patients’ death is associated with better bereavement adjustment.

As for why caregivers appear to benefit more than the patients from the parallel palliative care interventions, Dr. Bakitas said in an interview it may be the timing of the assessments, adding that other studies have shown an impact of palliative care at 4 months, but not at 3 months.

[email protected]

CHICAGO – Early palliative care delivered almost exclusively by telephone improved survival among patients with advanced cancer in the ENABLE III study.

After a median follow-up of a little more than 1 year, 46% of patients receiving palliative care from the time of cancer diagnosis and 54% of those with delayed palliative care had died.

Overall median survival was 18.3 months for the immediate group and 11.9 months for the delayed group (P = .17).

In preplanned analyses, the risk of death at 1 year was significantly lower in the immediate group (hazard ratio 0.72; P = .003), with a catch-up effect thereafter, Marie Bakitas, DNSc, reported at the annual meeting of the American Society of Clinical Oncology.

"Enhanced medical care, reduced aggressive care and chemotherapy use, longer access to hospice, and biologic impacts of improved quality of life have all been proposed as mechanisms to explain this survival advantage," Dr. Bakitas said. "However, at the present time, we do not have the data to support a particular mechanism and we are actively exploring this question through secondary analyses."

ENABLE (Educate, Nurture, Advise, Before Life Ends) III is the first study to examine the timing of early palliative care, but not the first to identify a survival advantage.

A recent study (N. Engl. J. Med. 2010:363:733-42) found that patients with metastatic non–small cell lung cancer (NSCLC) who received palliative care at the time of randomization lived a significant 2.7 months longer than did those receiving standard oncologic care, despite receiving significantly less aggressive end-of-life care (33% vs. 54%).

In ENABLE III, 207 patients with advanced cancer, and their caregivers, were randomized as a dyad to begin usual cancer care plus the intervention at the time of diagnosis (immediate group) or usual care alone for 3 months followed by the intervention (delayed group).

The intervention consisted of a traditional outpatient palliative care consult and six weekly structured telephone calls with a nurse coach using a guidebook that covers such topics as problem solving, symptom management, communication, and advanced care planning, explained Dr. Bakitas, the Marie O’Koren Endowed Chair and Professor, School of Nursing, and associate director of the Center for Palliative and Supportive Care, University of Alabama, Birmingham.

Usual care included the clinical consult, but not the telephone intervention.

The participants’ mean age was 64 years, half were male, 60% lived in a rural area, and 65% were married or living with a partner. Lung cancer was the most common diagnosis at 42%.

At baseline, 75% of patients were receiving chemotherapy, 19% were undergoing radiation, and 43% had an advanced directive completed at diagnosis.

Unlike the group’s prior trial comparing palliative care to usual care at 3 months, immediate versus delayed palliative care did not lead to significant improvements in quality of life on the Functional Assessment of Chronic Illness Therapy-Palliative care scale (129.9 vs. 127.2; P = .34), mood on the Center for Epidemiologic Studies Depression scale (11.2 vs. 10.8; P = .33), or symptom impact on the Quality of Life at the End of Life symptom impact subscale (11.4 vs. 12.2; P = .09).

One plausible reason for the findings is that there may not have been enough care differences between the two groups, with 40% of the delayed group receiving their first palliative care contact an average of 30 days before they were scheduled to do so on day 84, Dr. Bakitas said.

Second, difficulties in accrual and decreased study power may have made it difficult to pick up between-group differences on the subjective instruments, resulting in a type 2 error.

"A 3-month delay is still very early," Dr. Bakitas said.

She noted that early intervention allowed the palliative care team to have contact with patients for 1 year on average (range 240-493 days), compared with a median of 41-90 days from referral to death reported for outpatient clinics in a national survey of 142 National Cancer Institute and non-NCI cancer centers (JAMA 2010;303:1054-61).

Resource and chemotherapy use in ENABLE III was also comparable in both groups. Decedents in the immediate and delayed groups spent a median of 5 and 6 days, respectively, in hospital in the 7-9 months preceding death, while 8% and 5% received chemotherapy in the last 2 weeks of life.

This compares favorably with a national average of more than 8 hospital days in the last 6 months of life observed in the 2014 Dartmouth Atlas of Health Care, and a chemotherapy rate of 17.5% reported in the previously noted NSCLC study, Dr. Bakitas said.

She called for more studies of early palliative care to determine the optimal timing, personnel, essential elements, and mechanisms of improved survival.

"While the benefits of these approaches have been demonstrated when provided early after a cancer diagnosis, in practice these potentially beneficial palliative care services are often provided very late, sometimes hours or weeks before death," Dr. Bakitas said. "This trend is likely to continue in the absence of clear direction on the very pragmatic questions of who, what, and when."

The study was funded by National Institute for Nursing Research. Dr. Bakitas reported having no relevant disclosures.

Palliative care support buoys caregivers of advanced cancer patients

Providing early palliative care support to caregivers of advanced cancer patients improves their quality of life, depression, and stress burden, the ENABLE III study found.

"Similar to patients, waiting to provide these caregiver services until patients are in their last weeks to days of life may not adequately address the distress that they experience," Nick Dionne-Odom, Ph.D., RN, said at the meeting.

Caregivers for the 13 million cancer patients in the United States living with advanced disease can spend up to 8 hours per day providing assistance in activities that include symptom management, emotional and spiritual support, meal preparation, arranging medical appointments, and transportation.

The combination of this burden and witnessing someone close to you struggle with illness can cause psychological distress equal to or sometimes greater than that experienced by the patient, said Dr. Dionne-Odom, a postdoctoral fellow at the University of Alabama at Birmingham.

In ENABLE III, 122 caregivers were randomized at the time of the patient’s cancer diagnosis or 12 weeks later to a palliative care intervention that consisted of three weekly structured educational telephone calls from an advanced practice nurse coach, monthly check-in calls to address new or ongoing issues, and a bereavement call for caregivers whose loved ones died.

Caregivers were not restricted to family members, but could include close friends and even neighbors. Their mean age was 60 years, 79% were female, 75% were spouses, and all had at least a high school education.

At 12 weeks from the start of the intervention, caregivers in the immediate versus delayed group had significantly better quality of life on the Caregiver Quality of Life Index–Cancer scale (mean 50.2 vs. 56.1; P = .02) and less depressive symptoms on the Center for Epidemiologic Studies Depression (CESD) scale (10.2 vs. 16.6; P = .0006), Dr. Dionne-Odom said. Notably, the delayed group surpassed the clinical cutoff for depression of 16 on the CESD scale, he added.

The intervention did not appear to change the perception among caregivers of what was demanded of them by the patient or their objective burden, though there was a trend among the immediate group for improved caregiver stress burden on the Montgomery Borgatta Caregiver Burden Scale (13.2 vs. 13.8; P = .10).

There was no significant difference between groups in depression or grief scores for caregivers of decedents. A difference may have been detected with a larger sample size, he said, adding that prior studies have shown that reducing caregiver stress before patients’ death is associated with better bereavement adjustment.

As for why caregivers appear to benefit more than the patients from the parallel palliative care interventions, Dr. Bakitas said in an interview it may be the timing of the assessments, adding that other studies have shown an impact of palliative care at 4 months, but not at 3 months.

[email protected]

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Today our team saw an 89-year-old gentleman on the hospitalist service with dementia, heart failure, atrial fibrillation, chronic kidney disease, and problems falling. His last known fall was less than 3 months ago and resulted in a broken hip requiring surgical intervention. This was his fourth hospitalization in 6 months, yet it was the first time he was seen by our service.

The frequency at which palliative care (PC) consults are ordered in a particular hospital varies widely. Some reasons for this are not easy fixes – PC is not available in each hospital (as was the case in two of this gentleman’s four hospitalizations), many PC teams are available only Monday-Friday, and patient volumes within a hospital ebb and flow with much less predictability than the tides.

However, some of the reasons are amenable to change. These might include the particular group of hospitalists, or one attending physician, utilizing PC consults less frequently than another. Or it may simply be that the connection was not made between the patient’s experience and the usefulness of an early PC consults. Screening tools are one method of decreasing variability in PC involvement as well as increasing the appropriateness of our service for a particular patient.

There are quite a few palliative care screening tools available. Many of them focus on what most of us would expect, which are the most common diagnoses we see (late-stage cancer, HF, cirrhosis, end-stage renal disease, dementia, etc.). Multiple studies have estimated that mature PC programs in large hospitals are consulted on 1%-2% of live discharges. However, we estimate that more than 10% of these discharged patients have palliative needs that go unmet. While it is true that we wish PC could be involved in all of these lives, this large number of people who spend time in the hospital with these diagnoses, coupled with a national shortage of PC providers, translates into an unbalanced equation.

Rather than looking at a specific diagnosis, we suggest incorporating inquiries on the presence of "palliative care–related problems." While these might require more thought or investigation into a patient’s situation, we find them to be more fruitful than using diagnosis alone.

Some examples? Mismatch between the expectations of the medical team vs. patient/family when it comes to prognosis or the goals of care would be one of them. Another might be persistent uncontrolled symptoms despite usual medical management. Family members disagreeing or demonstrating concerns about the goals of care is still another.

Having used various screening tools in multiple hospitals and clinical settings, we suggest the following considerations in setting up your own:

• Stakeholder management: The right services and staff need to agree on this being a way to improve quality of care (we always provide an "opt-out" option for those who don’t want us involved for some reason).

• Start small: Implement these on one unit at a time or limit the diagnoses to one or two conditions only. You can make the criteria less stringent if the PC team’s bandwidth is not too narrow.

• Be flexible: Even by starting small, there will be times that the PC teams are overwhelmed on a particular day leaving the occasional patient who meets criteria unseen. If the consult is urgent, a phone call is appropriate so that an assumption isn’t made that the screening tool will catch 100% of the patients.

• Track data: When using these tools, palliative care teams have been able to show things such as improved Hospital Consumer Assessment of Healthcare Providers and Systems survey results and decreased readmissions. Demonstrate what you’re doing for your institution so that you can expand the units or patients served.

PC screening tools are an effective way to decrease variability and improve quality. For examples of tools that we use, please get in touch. Find our contact info and read earlier columns at ehospitalistnews/Palliatively.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.

Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.

Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.

In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.

Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.

In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.

The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).

In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.

‘No reports of clinical recovery’

However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."

It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).

These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.

A single exam

In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.

Confounded by movement

Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.

This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.

Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.

Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO₂ of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.

Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.

Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.

In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).

Controversy over ancillary testing

There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.

Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.

It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.

It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).

A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.

Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.

Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.

Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.

Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.

In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.

Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.

In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.

The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).

In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.

‘No reports of clinical recovery’

However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."

It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).

These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.

A single exam

In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.

Confounded by movement

Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.

This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.

Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.

Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO₂ of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.

Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.

Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.

In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).

Controversy over ancillary testing

There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.

Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.

It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.

It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).

A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.

Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.

Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.

Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.

Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.

In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.

Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.

In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.

The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).

In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.

‘No reports of clinical recovery’

However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."

It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).

These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.

A single exam

In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.

Confounded by movement

Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.

This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.

Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.

Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO₂ of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.

Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.

Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.

In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).

Controversy over ancillary testing

There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.

Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.

It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.

It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).

A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.

Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.