Hospice & Palliative Medicine

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.

The opioid prescription rates have significantly decreased for children, teens, and younger adults between 2006 and 2018, according to new research.

“What’s important about this new study is that it documented that these improvements were also occurring for children and young adults specifically,” said Kao-Ping Chua, MD, PhD, primary care physician and assistant professor of pediatrics at the University of Michigan, Ann Arbor, who was not involved in the study. “The reason that’s important is that changes in medical practice for adults aren’t always reflected in pediatrics.”

The study, published in JAMA Pediatrics, found that dispensed opioid prescriptions for this population have decreased by 15% annually since 2013. However, the study also examined specific prescribing variables, such as duration of opioid prescription and high-dosage prescriptions. Researchers found reduced rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, these types of prescription practices increased in children aged 0-5 years.

“I think [the findings are] promising, suggesting that opiate prescribing practices may be improving,” study author Madeline Renny, MD, pediatric emergency medicine doctor at New York University Langone Health, said in an interview. “But we did find that there were increases in the young children for the practice variables, which we didn’t expect. I think that was kind of one of the findings that we were a bit surprised about and want to explore further.”

Previous studies have linked prescription opioid use in children and teens to an increased risk of future opioid misuse. A 2015 study published in Pediatrics found that using prescribed opioids before the 12th grade is associated with a 33% increase in the risk of future opioid misuse by the age of 23. The study also found that for those with a low predicted risk of future opioid misuse, an opioid prescription increases the risk for misuse after high school threefold.

Furthermore, a 2018 study published in JAMA Network Open found that, between 1999 and 2016, the annual estimated mortality rate for all children and adolescents from prescription and illicit opioid use rose 268.2%.

In the new study, Dr. Renny and colleagues examined data from 2006 to 2018 from IQVIA Longitudinal Prescription Data, which captured 74%-92% of U.S. retail outpatient opioid prescriptions dispensed to people up to the age of 24. Researchers also examined prescribing practice variables, which included opioid dispensing rates, average amount of opioid dispensed per prescription, duration of opioid prescription, high-dosage opioid prescription for individuals, and the rate in which extended-release or long-acting opioids are prescribed.

Researchers found that between 2006 and 2018, the total U.S. annual opioid prescriptions dispensed to patients younger than 25 years was highest in 2007 at 15,689,779 prescriptions, and since 2012 has steadily decreased to 6,705,478 in 2018.

“Our study did show that there were declines, but opioids remain readily dispensed,” Dr. Renny said. “And I think it’s good that rates have gone down, but I think opioids are still commonly dispensed to children and adolescents and young adults and all of our age groups.”

Dr. Chua said that the study was important, but when it came to younger children, it didn’t account for the fact that “the underlying population of patients who were getting opioids changed because it’s not the same group of children.”

“Maybe at the beginning there were more surgical patients who are getting shorter duration, lower dosage opioids,” he added. “Now some of those surgical exceptions kind of went away and who’s left in the population of people who get opioids is a sicker population.”

“Who are the 0 to 5-year-olds who are getting opioids now?” Dr. Chua asked. “Well, some of them are going to be cancer or surgical patients. If you think about it, over time their surgeons may be more judicious and they stop prescribing opioids for some things like circumcision or something like that. So that means that who’s left in the population of children who get opiate prescriptions are the cancer patients. Cancer patients’ opioid dosages are going to be higher because they have chronic pain.”

Dr. Chua said it is important to remember that the number of children who are affected by those high-risk prescriptions are lower because the overall number of opioid prescriptions has gone down. He added that the key piece of missing information is the absolute number of prescriptions that were high risk.

Researchers of the current study suggested that, because of the differences between pediatric and adult pain and indications for opioid prescribing, there should be national guidelines on general opioid prescribing for children and adolescents.

Experts did not disclose relevant financial relationships.

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences for future medical care, according to Meredith A. MacMartin, MD, director of inpatient palliative care at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

ACP “is really about planning for care in advance,” and in many ways, the inpatient setting is uniquely suited to this process, Dr. MacMartin said in a presentation at SHM Converge 2021, the annual conference of the Society of Hospital Medicine. “The key part is the advance part. You want conversations to happen before the care is actually needed,” she said.

Dr. MacMartin emphasized the importance of distinguishing between ACP and advance directives (ADs). ACP is a process, whereas ADs are documentation, “ideally of the content of advance care planning discussions,” she explained. ACP involves discussion about what is important to the patients, their goals, what information is helpful for them, and whether their current care is aligned with their goals, Dr. MacMartin said. ADs might involve a designated power of attorney for health care, a living will, and, in some states, specific clinician-signed orders regarding resuscitation or transport to hospital.

ACP is “more than whether a patient wants CPR [cardiopulmonary resuscitation] or not,” said Dr. MacMartin. ACP matters because it helps ensure that the care a patient receives aligns with the patient’s wishes and values, she said. ACP increases the likelihood that patients will die in their preferred locations, it allows them to discuss their wishes and prepare for decline, and it relieves family members of the burden of decision making, she said. From a hospital perspective, data show that use of an ACP can decrease intensive care unit (ICU) utilization and overall health care costs. “Often, when people are given the opportunity to express their wishes, they get less unnecessary care,” Dr. MacMartin noted.

Although ACP often takes place in an outpatient setting, hospitalists are in a unique position to conduct some ACP conversations with their patients, Dr. MacMartin said. “Hospitalists are available” and are physically present at least once a day, so there is a pragmatic advantage. Also, some data suggest that patients may feel more comfortable having ACP conversations with a hospitalist than with a primary care provider with whom they have a long-standing relationship, Dr. MacMartin added.

Another important advantage of ACP in the hospital setting is that, “as hospitalists, you are the expert on inpatient illness; you know what sick looks like, and you have a unique perspective on prognostication that may be harder to recreate in the outpatient setting,” Dr. MacMartin said.
 

Barriers to ACP include patient identification, logistics, attitudes

Settings in which ACP is appropriate include those in which a patient is undergoing “sentinel hospitalization,” meaning that the patient is at a transition point in the disease course. Examples are a patient newly diagnosed with metastatic solid cancer, a patient with progressive chronic kidney disease who is considering hemodialysis, or a patient who receives treatment in the ICU for longer than 7 days, Dr. MacMartin said.

Guidelines for identifying patients who might benefit from ACP include the use of the “surprise question” (“would you be surprised if this patient dies in the next year?”) as well as functional status assessments using tools such as the Australia-modified Karnofsky Performance Status or the Eastern Cooperative Oncology Group score, said Dr. MacMartin. Some studies suggest that any hospitalized patient older than 65 years should have an ACP discussion, she added.

Time pressure remains a significant barrier to ACP conversations. Some strategies to overcome this problem include enlisting help from other specialists, particularly social workers, Dr. MacMartin said. Social workers report a higher comfort level for talking to patients about death than any other medical specialty; “this is something they want to be doing,” she said. Also, the possibility of reimbursement may act as a buffer to create more time to have ACP conversations with patients, she noted.

Addressing clinicians’ discomfort with ACP conversations can be “a tougher nut to crack,” Dr. MacMartin acknowledged. Clinicians report that they don’t want to cause their patients distress, and some report that having conversations about end-of-life care is distressing for them as well. Some of these barriers can be overcome with skills training, including use of a prepared guideline or framework to help increase the comfort level for both clinicians and patients, said Dr. MacMartin.
 

A look ahead: Training strategies and COVID-19 impact

“For hospitalists interested in developing their ACP skills, I highly recommend two resources,” Dr. MacMartin said in an interview. “The Serious Illness Conversation Guide, from Ariadne Labs, is an excellent tool for any clinician to guide discussion about a patient’s goals and values,” she said.

“For clinicians wanting to build or improve their communication, including advance care planning discussions but also topics like responding to patient’s emotions, VitalTalk training offers a deeper dive into core communications skills,” she added.

“If your hospital has a palliative care team, they may also have more local resources available to you. To learn more about billing for ACP discussions, I recommend starting with your institutional billing and coding group, as these practices vary some between practices, and they will be able to provide the best guidance for clinicians. These are new codes that aren’t yet being very widely used so it’s a chance to innovate,” Dr. MacMartin noted.

“The hospital setting is an opportunity for patients to reflect on their health, both present and in the future, with a physician who has expertise in acute illness and prognostication and who is available for discussion on a daily basis during the hospitalization,” Dr. MacMartin emphasized.

As for whether the COVID-19 pandemic has affected ACP in the inpatient setting, the data are limited, but more information is forthcoming, Dr. MacMartin said. “In my personal experience and in talking to colleagues elsewhere, the pandemic has highlighted the need for ACP in some ways, as we have tried to ensure that people who wouldn’t want things like intensive care are identified early,” she said. “I hope that some of the workflows developed to identify patients who should get ACP in the hospital stay in practice and are strengthened over time,” she added.

Dr. MacMartin has disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.

At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.

“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.

Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.

Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.

“Consistency was the key,” Dr. Stein said.

At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.

“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”

The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.

The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.

The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.

“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.

New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.

The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.

The broad perspective was important, Dr. Singh said.

“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
 

Palliative care and patient flow

Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.

A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.

These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.

At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.

Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”

“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
 

With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.

At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.

“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.

Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.

Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.

“Consistency was the key,” Dr. Stein said.

At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.

“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”

The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.

The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.

The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.

“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.

New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.

The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.

The broad perspective was important, Dr. Singh said.

“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
 

Palliative care and patient flow

Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.

A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.

These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.

At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.

Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”

“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
 

With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.

At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.

“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.

Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.

Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.

“Consistency was the key,” Dr. Stein said.

At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.

“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”

The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.

The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.

The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.

“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.

New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.

The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.

The broad perspective was important, Dr. Singh said.

“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
 

Palliative care and patient flow

Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.

A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.

These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.

At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.

Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”

“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
 

Study Overview

Objective. To examine the patterns in palliative care delivery in the last year of life among adults with cancer compared with adults with a noncancer terminal diagnosis.

Design. Population-based cohort study in Ontario, Canada, using linked administrative and clinical databases. The study included all adults ages 18 and over who died of cancer or noncancer terminal illnesses and received physician-delivered palliative care that was initiated in the last year of life between January 2010 and December 2017. These palliative care services are identified through the use of claims fee codes by physicians that account for delivery of palliative care, such as symptom management and counseling, that are intended to be palliative rather than curative. Exclusion criteria include patients who had 2 or more palliative care service claims the year prior to the last year of life, which may indicate existing palliative care services rather than initiation of new palliative care services in the last year of life. Other patients who were excluded from the study had palliative care services initiated within 7 days of death, as it is less likely that services and support would be arranged prior to death given the short time frame. The types of noncancer illnesses included heart failure, chronic obstructive pulmonary disease, end-stage renal disease, cirrhosis, stroke, and dementia. For the comparison of palliative care services, types of illnesses were divided into cancer, chronic organ failure (heart failure, chronic pulmonary disease, end-stage renal disease, cirrhosis, or stroke), and dementia, as they may represent different trajectories of illnesses and needs.

Setting and participants. The study included 145 709 adults who died during the study period, among 351 941 adults who died from illnesses described above. Another 105 587 were excluded because there were no palliative care services before death, 48 525 were excluded because of existing palliative care services prior to the last year of life, and 44 164 were excluded because palliative care was initiated within 7 days of death. Among the study population included, 21 054 died of chronic organ failure, 14 033 died of dementia, and 110 622 died of cancer. The median age of the study population was 78 years, with an interquartile range of 67 to 86 years, and 50.7% were female. Approximately 12.8% of the study population reside in rural areas; median frailty score (hospital frailty risk score) among those who died of chronic organ failure was 10, and the score among those who died of dementia was 13. The frailty score among those who died of cancer was 3, indicating less frailty. Those who died of organ failure and dementia also had a high mean number of prescription medications (18 and 16, respectively) compared with those with cancer (11).

Main outcome measures. Study outcome measures include the timing of palliative care initiation (primary outcome), categorized into time frames of ≤ 30 days, 31 to 90 days, and > 90 days before death; location of initiation of palliative care services, categorized into clinic, home, hospital, subacute care, and case management; models of care, categorized as generalist, consultative, or specialist palliative care; total number of palliative care visits before death; and location of death. The models of palliative care delivery were categorized based on the proportion of palliative care fee codes claimed by physicians. Physicians whose annual billing included more than 10% of palliative care service codes were considered palliative care specialists. Using this designation, models of palliative care were categorized into those delivered by palliative care specialists, generalists (nonpalliative care specialists), or both.

Main results. The study found that the timing of palliative care initiation was earlier among those who died of cancer compared with those with organ failure or dementia (28.9% vs 15.9% and 15.3%, respectively). After adjustment, those who died of organ failure and those who died of dementia were less likely to have palliative care services initiated > 90 days prior to death (odds ratio [OR] 0.48 and 0.42, respectively) and between 31 to 90 days prior to death (OR 0.77 and 0.60, respectively), when compared with those who died of cancer (who served as the reference group). Regarding location of palliative care initiation, adults who died of cancer were less likely to have palliative care services initiated at home (14.5%) compared with those who died of organ failure (32.8%) or dementia (27.9%). Overall, those who died of cancer received more palliative care visits from initiation to death (median of 11 visits) compared with those who died oforgan failure (median 4 visits) and dementia (median 4 visits). Regarding models of palliative care delivery, a higher proportion of palliative care was delivered by palliative care specialists rather than generalists among cancer patients (72.9%) compared with those with organ failure (43.3%) or dementia (40.1%). The proportion of patients with cancer who died at home was 62.6%, which was higher than those with organ failure (53.3%) but lower than those with dementia (75%).

Conclusion. There are differences in the delivery of palliative care among patients with cancer and other noncancer terminal illnesses, including timing of initiation of palliative care services, location of services, number of visits, and delivery by types of practitioners of palliative care. Understanding these disparities and targeting them are potentially important steps to ensuring appropriate access to palliative care across settings and disease types.

Commentary

Palliative care improves the quality of life of patients with serious illnesses and reduces symptom burden, and results in better satisfaction and less burdensome care.¹ Although palliative care approaches have been championed for cancer management, there is increasing evidence that palliative care also improves outcomes for patients with noncancer illnesses such as heart failure.² This study highlights the differences in palliative care delivery for patients who have cancer and noncancer diagnoses, demonstrating that timing, location, and care delivery models differ among patients with different diagnoses. The finding that noncancer terminal illness often has later palliative care initiation is a significant one, as early palliative care has been associated with improved patient outcomes³; thus, efforts to initiate palliative care earlier in the course of illness may benefit these patients.

A particular challenge in determining when to initiate palliative care lies in predicting outcomes,⁴ particularly for different types of illnesses, which may have different trajectories of advancing disease and functional change. Recent research has tested novel prognostic approaches, such as using machine learning to generate mortality estimates and integrating them into clinical decision support.⁵ These approaches may have the potential to enhance palliative care delivery and may be adapted to be used in managing patients with noncancer illnesses as well. The study also found that patients with cancer were more likely to receive palliative care from specialists rather than generalists, although this could be due to how palliative care is integrated in hospitals, clinics, and systems of care that serve patients with cancer. Identifying approaches that yield better palliative care models and delivery may help to further enhance care for patients with noncancer illnesses.

Applications for Clinical Practice

Identifying differences in patterns of palliative care delivery among those with cancer and other diagnoses may be an important step towards identifying gaps and avenues to improve palliative care delivery. The underlying reasons for these differences could be targeted so that patients across settings and diagnoses may have equal access to palliative care to improve their symptoms and quality of life. Policy makers and health system leaders may consider learning from how palliative care has been integrated into oncology care, to help transform care delivery for other noncancer terminal illnesses. It may also involve broadening education to providers in different specialties, so that the value and importance of palliative care may be recognized beyond oncological care.

Study Overview

Objective. To examine the patterns in palliative care delivery in the last year of life among adults with cancer compared with adults with a noncancer terminal diagnosis.

Design. Population-based cohort study in Ontario, Canada, using linked administrative and clinical databases. The study included all adults ages 18 and over who died of cancer or noncancer terminal illnesses and received physician-delivered palliative care that was initiated in the last year of life between January 2010 and December 2017. These palliative care services are identified through the use of claims fee codes by physicians that account for delivery of palliative care, such as symptom management and counseling, that are intended to be palliative rather than curative. Exclusion criteria include patients who had 2 or more palliative care service claims the year prior to the last year of life, which may indicate existing palliative care services rather than initiation of new palliative care services in the last year of life. Other patients who were excluded from the study had palliative care services initiated within 7 days of death, as it is less likely that services and support would be arranged prior to death given the short time frame. The types of noncancer illnesses included heart failure, chronic obstructive pulmonary disease, end-stage renal disease, cirrhosis, stroke, and dementia. For the comparison of palliative care services, types of illnesses were divided into cancer, chronic organ failure (heart failure, chronic pulmonary disease, end-stage renal disease, cirrhosis, or stroke), and dementia, as they may represent different trajectories of illnesses and needs.

Setting and participants. The study included 145 709 adults who died during the study period, among 351 941 adults who died from illnesses described above. Another 105 587 were excluded because there were no palliative care services before death, 48 525 were excluded because of existing palliative care services prior to the last year of life, and 44 164 were excluded because palliative care was initiated within 7 days of death. Among the study population included, 21 054 died of chronic organ failure, 14 033 died of dementia, and 110 622 died of cancer. The median age of the study population was 78 years, with an interquartile range of 67 to 86 years, and 50.7% were female. Approximately 12.8% of the study population reside in rural areas; median frailty score (hospital frailty risk score) among those who died of chronic organ failure was 10, and the score among those who died of dementia was 13. The frailty score among those who died of cancer was 3, indicating less frailty. Those who died of organ failure and dementia also had a high mean number of prescription medications (18 and 16, respectively) compared with those with cancer (11).

Main outcome measures. Study outcome measures include the timing of palliative care initiation (primary outcome), categorized into time frames of ≤ 30 days, 31 to 90 days, and > 90 days before death; location of initiation of palliative care services, categorized into clinic, home, hospital, subacute care, and case management; models of care, categorized as generalist, consultative, or specialist palliative care; total number of palliative care visits before death; and location of death. The models of palliative care delivery were categorized based on the proportion of palliative care fee codes claimed by physicians. Physicians whose annual billing included more than 10% of palliative care service codes were considered palliative care specialists. Using this designation, models of palliative care were categorized into those delivered by palliative care specialists, generalists (nonpalliative care specialists), or both.

Main results. The study found that the timing of palliative care initiation was earlier among those who died of cancer compared with those with organ failure or dementia (28.9% vs 15.9% and 15.3%, respectively). After adjustment, those who died of organ failure and those who died of dementia were less likely to have palliative care services initiated > 90 days prior to death (odds ratio [OR] 0.48 and 0.42, respectively) and between 31 to 90 days prior to death (OR 0.77 and 0.60, respectively), when compared with those who died of cancer (who served as the reference group). Regarding location of palliative care initiation, adults who died of cancer were less likely to have palliative care services initiated at home (14.5%) compared with those who died of organ failure (32.8%) or dementia (27.9%). Overall, those who died of cancer received more palliative care visits from initiation to death (median of 11 visits) compared with those who died oforgan failure (median 4 visits) and dementia (median 4 visits). Regarding models of palliative care delivery, a higher proportion of palliative care was delivered by palliative care specialists rather than generalists among cancer patients (72.9%) compared with those with organ failure (43.3%) or dementia (40.1%). The proportion of patients with cancer who died at home was 62.6%, which was higher than those with organ failure (53.3%) but lower than those with dementia (75%).

Conclusion. There are differences in the delivery of palliative care among patients with cancer and other noncancer terminal illnesses, including timing of initiation of palliative care services, location of services, number of visits, and delivery by types of practitioners of palliative care. Understanding these disparities and targeting them are potentially important steps to ensuring appropriate access to palliative care across settings and disease types.

Commentary

Palliative care improves the quality of life of patients with serious illnesses and reduces symptom burden, and results in better satisfaction and less burdensome care.¹ Although palliative care approaches have been championed for cancer management, there is increasing evidence that palliative care also improves outcomes for patients with noncancer illnesses such as heart failure.² This study highlights the differences in palliative care delivery for patients who have cancer and noncancer diagnoses, demonstrating that timing, location, and care delivery models differ among patients with different diagnoses. The finding that noncancer terminal illness often has later palliative care initiation is a significant one, as early palliative care has been associated with improved patient outcomes³; thus, efforts to initiate palliative care earlier in the course of illness may benefit these patients.

A particular challenge in determining when to initiate palliative care lies in predicting outcomes,⁴ particularly for different types of illnesses, which may have different trajectories of advancing disease and functional change. Recent research has tested novel prognostic approaches, such as using machine learning to generate mortality estimates and integrating them into clinical decision support.⁵ These approaches may have the potential to enhance palliative care delivery and may be adapted to be used in managing patients with noncancer illnesses as well. The study also found that patients with cancer were more likely to receive palliative care from specialists rather than generalists, although this could be due to how palliative care is integrated in hospitals, clinics, and systems of care that serve patients with cancer. Identifying approaches that yield better palliative care models and delivery may help to further enhance care for patients with noncancer illnesses.

Applications for Clinical Practice

Identifying differences in patterns of palliative care delivery among those with cancer and other diagnoses may be an important step towards identifying gaps and avenues to improve palliative care delivery. The underlying reasons for these differences could be targeted so that patients across settings and diagnoses may have equal access to palliative care to improve their symptoms and quality of life. Policy makers and health system leaders may consider learning from how palliative care has been integrated into oncology care, to help transform care delivery for other noncancer terminal illnesses. It may also involve broadening education to providers in different specialties, so that the value and importance of palliative care may be recognized beyond oncological care.

Study Overview

Objective. To examine the patterns in palliative care delivery in the last year of life among adults with cancer compared with adults with a noncancer terminal diagnosis.

Design. Population-based cohort study in Ontario, Canada, using linked administrative and clinical databases. The study included all adults ages 18 and over who died of cancer or noncancer terminal illnesses and received physician-delivered palliative care that was initiated in the last year of life between January 2010 and December 2017. These palliative care services are identified through the use of claims fee codes by physicians that account for delivery of palliative care, such as symptom management and counseling, that are intended to be palliative rather than curative. Exclusion criteria include patients who had 2 or more palliative care service claims the year prior to the last year of life, which may indicate existing palliative care services rather than initiation of new palliative care services in the last year of life. Other patients who were excluded from the study had palliative care services initiated within 7 days of death, as it is less likely that services and support would be arranged prior to death given the short time frame. The types of noncancer illnesses included heart failure, chronic obstructive pulmonary disease, end-stage renal disease, cirrhosis, stroke, and dementia. For the comparison of palliative care services, types of illnesses were divided into cancer, chronic organ failure (heart failure, chronic pulmonary disease, end-stage renal disease, cirrhosis, or stroke), and dementia, as they may represent different trajectories of illnesses and needs.

Setting and participants. The study included 145 709 adults who died during the study period, among 351 941 adults who died from illnesses described above. Another 105 587 were excluded because there were no palliative care services before death, 48 525 were excluded because of existing palliative care services prior to the last year of life, and 44 164 were excluded because palliative care was initiated within 7 days of death. Among the study population included, 21 054 died of chronic organ failure, 14 033 died of dementia, and 110 622 died of cancer. The median age of the study population was 78 years, with an interquartile range of 67 to 86 years, and 50.7% were female. Approximately 12.8% of the study population reside in rural areas; median frailty score (hospital frailty risk score) among those who died of chronic organ failure was 10, and the score among those who died of dementia was 13. The frailty score among those who died of cancer was 3, indicating less frailty. Those who died of organ failure and dementia also had a high mean number of prescription medications (18 and 16, respectively) compared with those with cancer (11).

Main outcome measures. Study outcome measures include the timing of palliative care initiation (primary outcome), categorized into time frames of ≤ 30 days, 31 to 90 days, and > 90 days before death; location of initiation of palliative care services, categorized into clinic, home, hospital, subacute care, and case management; models of care, categorized as generalist, consultative, or specialist palliative care; total number of palliative care visits before death; and location of death. The models of palliative care delivery were categorized based on the proportion of palliative care fee codes claimed by physicians. Physicians whose annual billing included more than 10% of palliative care service codes were considered palliative care specialists. Using this designation, models of palliative care were categorized into those delivered by palliative care specialists, generalists (nonpalliative care specialists), or both.

Main results. The study found that the timing of palliative care initiation was earlier among those who died of cancer compared with those with organ failure or dementia (28.9% vs 15.9% and 15.3%, respectively). After adjustment, those who died of organ failure and those who died of dementia were less likely to have palliative care services initiated > 90 days prior to death (odds ratio [OR] 0.48 and 0.42, respectively) and between 31 to 90 days prior to death (OR 0.77 and 0.60, respectively), when compared with those who died of cancer (who served as the reference group). Regarding location of palliative care initiation, adults who died of cancer were less likely to have palliative care services initiated at home (14.5%) compared with those who died of organ failure (32.8%) or dementia (27.9%). Overall, those who died of cancer received more palliative care visits from initiation to death (median of 11 visits) compared with those who died oforgan failure (median 4 visits) and dementia (median 4 visits). Regarding models of palliative care delivery, a higher proportion of palliative care was delivered by palliative care specialists rather than generalists among cancer patients (72.9%) compared with those with organ failure (43.3%) or dementia (40.1%). The proportion of patients with cancer who died at home was 62.6%, which was higher than those with organ failure (53.3%) but lower than those with dementia (75%).

Conclusion. There are differences in the delivery of palliative care among patients with cancer and other noncancer terminal illnesses, including timing of initiation of palliative care services, location of services, number of visits, and delivery by types of practitioners of palliative care. Understanding these disparities and targeting them are potentially important steps to ensuring appropriate access to palliative care across settings and disease types.

Commentary

Palliative care improves the quality of life of patients with serious illnesses and reduces symptom burden, and results in better satisfaction and less burdensome care.¹ Although palliative care approaches have been championed for cancer management, there is increasing evidence that palliative care also improves outcomes for patients with noncancer illnesses such as heart failure.² This study highlights the differences in palliative care delivery for patients who have cancer and noncancer diagnoses, demonstrating that timing, location, and care delivery models differ among patients with different diagnoses. The finding that noncancer terminal illness often has later palliative care initiation is a significant one, as early palliative care has been associated with improved patient outcomes³; thus, efforts to initiate palliative care earlier in the course of illness may benefit these patients.

A particular challenge in determining when to initiate palliative care lies in predicting outcomes,⁴ particularly for different types of illnesses, which may have different trajectories of advancing disease and functional change. Recent research has tested novel prognostic approaches, such as using machine learning to generate mortality estimates and integrating them into clinical decision support.⁵ These approaches may have the potential to enhance palliative care delivery and may be adapted to be used in managing patients with noncancer illnesses as well. The study also found that patients with cancer were more likely to receive palliative care from specialists rather than generalists, although this could be due to how palliative care is integrated in hospitals, clinics, and systems of care that serve patients with cancer. Identifying approaches that yield better palliative care models and delivery may help to further enhance care for patients with noncancer illnesses.

Applications for Clinical Practice

Identifying differences in patterns of palliative care delivery among those with cancer and other diagnoses may be an important step towards identifying gaps and avenues to improve palliative care delivery. The underlying reasons for these differences could be targeted so that patients across settings and diagnoses may have equal access to palliative care to improve their symptoms and quality of life. Policy makers and health system leaders may consider learning from how palliative care has been integrated into oncology care, to help transform care delivery for other noncancer terminal illnesses. It may also involve broadening education to providers in different specialties, so that the value and importance of palliative care may be recognized beyond oncological care.

Restrictions due to COVID-19 created new challenges for maintaining the values of palliative care and educating medical students about it during the pandemic, Clarissa Johnston, MD, said during a virtual presentation at the annual meeting of the Society of General Internal Medicine.

Dr. Johnston, of the University of Texas at Austin, and colleagues experienced an extreme COVID-19 surge when they reopened after initial closure in the first weeks of the pandemic.

“Our hospital and clinics are the health care safety net in Austin, and we serve a predominantly uninsured and Hispanic population that experienced a greater burden of COVID-19 than other populations in our area,” she said in the presentation.

The rapid onset and spread of COVID-19 locally required physicians and staff to innovate quickly, and “we developed and implemented collaborative and novel partnerships between generalists and palliative care specialists to help ensure that our core humanizing values were not lost in the pandemic,” Dr. Johnston emphasized.

Collaboration between internal medicine and palliative care involved developing relationship-centered communication for families and health care workers, as well as engaging medical students in a Transitions of Care elective, Dr. Johnston said.

The early weeks of the pandemic impacted families with the no visitor policy and the loss of death rituals, she said. Health care providers suffered, too, as nurses experienced an overload of work, fears for their own health and safety, and feelings of disconnect from their patients. Physicians dealt with the challenges of a unique illness, and their own fears and uncertainty, Dr. Johnston said.
 

Meeting communication challenges

One of the strategies used to bridge the communication gap caused by the lack of visitors and family contact was the adoption of the Meet My Loved One program, adapted from a similar program at the University of Alabama, said Dr. Johnston. Meet My Loved One was a collaborative effort focused on ICU patients, Dr. Johnston said. Members of the primary care team, including medical students in the Transitions of Care elective, called family members of ICU patients to collect personal details and humanizing information about the patient, such as preferred name, favorite foods, favorite activities, and some personal history (i.e. played basketball when he was young), and this information was collated, summarized, and posted on the door of the patient’s room.

Advanced care conversations

Advanced care planning (ACP) benefits include not only the promotion of patient-centered care, but also decreases in ICU admissions, length of stay, and cost. Dr. Johnston and colleagues developed a multipronged curriculum that trainees could use to have ACP conversations with clinic patients who would be considered high risk if they developed COVID-19 infections, Dr. Johnston explained. As part of the elective, medical students were trained to have ACP conversations with patients via telehealth; students practiced role-playing conversations with each other via Zoom and met virtually as a group to review the conversations, she said.

Maintaining Humanity

“COVID-19 has changed the way we interact with patients and families,” Dr. Johnston said in an interview. The inability to rely on face-to-face discussions means that “we really need to think carefully how we maintain humanity and the human touch,” she said.

Challenges in providing palliative care during the pandemic include “maintaining humanity, remembering that there is a person behind the prone, paralyzed patient, with family members who love them, and are desperate to be with them but unable,” Dr. Johnston said.

“The Meet My Loved One program helped, as well as multidisciplinary rounds, chaplain services, and frequent check ins with the bedside nurses,” she said.

“I tried hard to call families every day to start to build that trust and rapport that was lost by all the distancing and lack of visits. I didn’t realize how much the day in and day out care of ICU patients is witnessed by families when they are in the room,” she noted. “During COVID-19, it was so much harder to build trust, especially when you add in the inequities and structural racism problems in our health care system,” she said.

“Why would a family member believe and trust some random doctor calling them on the phone? Were we really trying our hardest? Families didn’t have a way to assess that, at least not like they do when they are at bedside and see how hard everyone works,” Dr. Johnston said. “Video visits helped but were not the same.”

Some key lessons about palliative care Dr. Johnson said she learned from the pandemic were how important it is to remember the patient and family, “how we need to work to build trust,” and that clinicians should be mindful that video visits don’t work for everyone, and to “ask, ask, ask about what you don’t know, including death rituals.”

Additional research needs in palliative care in the wake of COVID-19 include more information on what works and what doesn’t work, from the patient and family perspective, said Dr. Johnston. Communication strategies are important, and “we need to address how we can better communicate around serious illness and end-of-life issues with Black and Brown communities,” she said.
 

Challenges of COVID care

One of the main challenges to providing palliative care in the early days of the pandemic was navigating the constantly evolving science of COVID-19, Aziz Ansari, DO, of Loyola University Chicago, Maywood, Ill., said in an interview.

“It was, and remains, very hard to prognosticate on how a patient will do having respiratory failure with COVID,” said Dr. Ansari, who was the leader of the Palliative Care interest group at the SGIM meeting.

“So, the challenge was how to have a conversation on goals, values, and preferences when we really did not know the disease entity,” Dr. Ansari noted.

“We were surprised many times [when patients with COVID-19] recovered though it took a long time, so we could not really say that in the acute phase of COVID, it was a terminal illness,” he noted.

“Regardless, it still behooves us to have conversations with our patients and families about what are they willing to go through, and how they define a quality of life,” he said.

Strategies such as those used at the University of Texas show the importance of primary care palliative skill development, said Dr. Ansari. “Every physician should have the skill set of having conversations with patients and families on goals, values, and preferences even in unknown situations,” he said. That lifelong skill set development begins in medical school, he added.

Dr. Johnston and Dr. Ansari had no financial conflicts to disclose.

Restrictions due to COVID-19 created new challenges for maintaining the values of palliative care and educating medical students about it during the pandemic, Clarissa Johnston, MD, said during a virtual presentation at the annual meeting of the Society of General Internal Medicine.

Dr. Johnston, of the University of Texas at Austin, and colleagues experienced an extreme COVID-19 surge when they reopened after initial closure in the first weeks of the pandemic.

“Our hospital and clinics are the health care safety net in Austin, and we serve a predominantly uninsured and Hispanic population that experienced a greater burden of COVID-19 than other populations in our area,” she said in the presentation.

The rapid onset and spread of COVID-19 locally required physicians and staff to innovate quickly, and “we developed and implemented collaborative and novel partnerships between generalists and palliative care specialists to help ensure that our core humanizing values were not lost in the pandemic,” Dr. Johnston emphasized.

Collaboration between internal medicine and palliative care involved developing relationship-centered communication for families and health care workers, as well as engaging medical students in a Transitions of Care elective, Dr. Johnston said.

The early weeks of the pandemic impacted families with the no visitor policy and the loss of death rituals, she said. Health care providers suffered, too, as nurses experienced an overload of work, fears for their own health and safety, and feelings of disconnect from their patients. Physicians dealt with the challenges of a unique illness, and their own fears and uncertainty, Dr. Johnston said.
 

Meeting communication challenges

One of the strategies used to bridge the communication gap caused by the lack of visitors and family contact was the adoption of the Meet My Loved One program, adapted from a similar program at the University of Alabama, said Dr. Johnston. Meet My Loved One was a collaborative effort focused on ICU patients, Dr. Johnston said. Members of the primary care team, including medical students in the Transitions of Care elective, called family members of ICU patients to collect personal details and humanizing information about the patient, such as preferred name, favorite foods, favorite activities, and some personal history (i.e. played basketball when he was young), and this information was collated, summarized, and posted on the door of the patient’s room.

Advanced care conversations

Advanced care planning (ACP) benefits include not only the promotion of patient-centered care, but also decreases in ICU admissions, length of stay, and cost. Dr. Johnston and colleagues developed a multipronged curriculum that trainees could use to have ACP conversations with clinic patients who would be considered high risk if they developed COVID-19 infections, Dr. Johnston explained. As part of the elective, medical students were trained to have ACP conversations with patients via telehealth; students practiced role-playing conversations with each other via Zoom and met virtually as a group to review the conversations, she said.

Maintaining Humanity

“COVID-19 has changed the way we interact with patients and families,” Dr. Johnston said in an interview. The inability to rely on face-to-face discussions means that “we really need to think carefully how we maintain humanity and the human touch,” she said.

Challenges in providing palliative care during the pandemic include “maintaining humanity, remembering that there is a person behind the prone, paralyzed patient, with family members who love them, and are desperate to be with them but unable,” Dr. Johnston said.

“The Meet My Loved One program helped, as well as multidisciplinary rounds, chaplain services, and frequent check ins with the bedside nurses,” she said.

“I tried hard to call families every day to start to build that trust and rapport that was lost by all the distancing and lack of visits. I didn’t realize how much the day in and day out care of ICU patients is witnessed by families when they are in the room,” she noted. “During COVID-19, it was so much harder to build trust, especially when you add in the inequities and structural racism problems in our health care system,” she said.

“Why would a family member believe and trust some random doctor calling them on the phone? Were we really trying our hardest? Families didn’t have a way to assess that, at least not like they do when they are at bedside and see how hard everyone works,” Dr. Johnston said. “Video visits helped but were not the same.”

Some key lessons about palliative care Dr. Johnson said she learned from the pandemic were how important it is to remember the patient and family, “how we need to work to build trust,” and that clinicians should be mindful that video visits don’t work for everyone, and to “ask, ask, ask about what you don’t know, including death rituals.”

Additional research needs in palliative care in the wake of COVID-19 include more information on what works and what doesn’t work, from the patient and family perspective, said Dr. Johnston. Communication strategies are important, and “we need to address how we can better communicate around serious illness and end-of-life issues with Black and Brown communities,” she said.
 

Challenges of COVID care

One of the main challenges to providing palliative care in the early days of the pandemic was navigating the constantly evolving science of COVID-19, Aziz Ansari, DO, of Loyola University Chicago, Maywood, Ill., said in an interview.

“It was, and remains, very hard to prognosticate on how a patient will do having respiratory failure with COVID,” said Dr. Ansari, who was the leader of the Palliative Care interest group at the SGIM meeting.

“So, the challenge was how to have a conversation on goals, values, and preferences when we really did not know the disease entity,” Dr. Ansari noted.

“We were surprised many times [when patients with COVID-19] recovered though it took a long time, so we could not really say that in the acute phase of COVID, it was a terminal illness,” he noted.

“Regardless, it still behooves us to have conversations with our patients and families about what are they willing to go through, and how they define a quality of life,” he said.

Strategies such as those used at the University of Texas show the importance of primary care palliative skill development, said Dr. Ansari. “Every physician should have the skill set of having conversations with patients and families on goals, values, and preferences even in unknown situations,” he said. That lifelong skill set development begins in medical school, he added.

Dr. Johnston and Dr. Ansari had no financial conflicts to disclose.

Restrictions due to COVID-19 created new challenges for maintaining the values of palliative care and educating medical students about it during the pandemic, Clarissa Johnston, MD, said during a virtual presentation at the annual meeting of the Society of General Internal Medicine.

Dr. Johnston, of the University of Texas at Austin, and colleagues experienced an extreme COVID-19 surge when they reopened after initial closure in the first weeks of the pandemic.

“Our hospital and clinics are the health care safety net in Austin, and we serve a predominantly uninsured and Hispanic population that experienced a greater burden of COVID-19 than other populations in our area,” she said in the presentation.

The rapid onset and spread of COVID-19 locally required physicians and staff to innovate quickly, and “we developed and implemented collaborative and novel partnerships between generalists and palliative care specialists to help ensure that our core humanizing values were not lost in the pandemic,” Dr. Johnston emphasized.

Collaboration between internal medicine and palliative care involved developing relationship-centered communication for families and health care workers, as well as engaging medical students in a Transitions of Care elective, Dr. Johnston said.

The early weeks of the pandemic impacted families with the no visitor policy and the loss of death rituals, she said. Health care providers suffered, too, as nurses experienced an overload of work, fears for their own health and safety, and feelings of disconnect from their patients. Physicians dealt with the challenges of a unique illness, and their own fears and uncertainty, Dr. Johnston said.
 

Meeting communication challenges

One of the strategies used to bridge the communication gap caused by the lack of visitors and family contact was the adoption of the Meet My Loved One program, adapted from a similar program at the University of Alabama, said Dr. Johnston. Meet My Loved One was a collaborative effort focused on ICU patients, Dr. Johnston said. Members of the primary care team, including medical students in the Transitions of Care elective, called family members of ICU patients to collect personal details and humanizing information about the patient, such as preferred name, favorite foods, favorite activities, and some personal history (i.e. played basketball when he was young), and this information was collated, summarized, and posted on the door of the patient’s room.

Advanced care conversations

Advanced care planning (ACP) benefits include not only the promotion of patient-centered care, but also decreases in ICU admissions, length of stay, and cost. Dr. Johnston and colleagues developed a multipronged curriculum that trainees could use to have ACP conversations with clinic patients who would be considered high risk if they developed COVID-19 infections, Dr. Johnston explained. As part of the elective, medical students were trained to have ACP conversations with patients via telehealth; students practiced role-playing conversations with each other via Zoom and met virtually as a group to review the conversations, she said.

Maintaining Humanity

“COVID-19 has changed the way we interact with patients and families,” Dr. Johnston said in an interview. The inability to rely on face-to-face discussions means that “we really need to think carefully how we maintain humanity and the human touch,” she said.

Challenges in providing palliative care during the pandemic include “maintaining humanity, remembering that there is a person behind the prone, paralyzed patient, with family members who love them, and are desperate to be with them but unable,” Dr. Johnston said.

“The Meet My Loved One program helped, as well as multidisciplinary rounds, chaplain services, and frequent check ins with the bedside nurses,” she said.

“I tried hard to call families every day to start to build that trust and rapport that was lost by all the distancing and lack of visits. I didn’t realize how much the day in and day out care of ICU patients is witnessed by families when they are in the room,” she noted. “During COVID-19, it was so much harder to build trust, especially when you add in the inequities and structural racism problems in our health care system,” she said.

“Why would a family member believe and trust some random doctor calling them on the phone? Were we really trying our hardest? Families didn’t have a way to assess that, at least not like they do when they are at bedside and see how hard everyone works,” Dr. Johnston said. “Video visits helped but were not the same.”

Some key lessons about palliative care Dr. Johnson said she learned from the pandemic were how important it is to remember the patient and family, “how we need to work to build trust,” and that clinicians should be mindful that video visits don’t work for everyone, and to “ask, ask, ask about what you don’t know, including death rituals.”

Additional research needs in palliative care in the wake of COVID-19 include more information on what works and what doesn’t work, from the patient and family perspective, said Dr. Johnston. Communication strategies are important, and “we need to address how we can better communicate around serious illness and end-of-life issues with Black and Brown communities,” she said.
 

Challenges of COVID care

One of the main challenges to providing palliative care in the early days of the pandemic was navigating the constantly evolving science of COVID-19, Aziz Ansari, DO, of Loyola University Chicago, Maywood, Ill., said in an interview.

“It was, and remains, very hard to prognosticate on how a patient will do having respiratory failure with COVID,” said Dr. Ansari, who was the leader of the Palliative Care interest group at the SGIM meeting.

“So, the challenge was how to have a conversation on goals, values, and preferences when we really did not know the disease entity,” Dr. Ansari noted.

“We were surprised many times [when patients with COVID-19] recovered though it took a long time, so we could not really say that in the acute phase of COVID, it was a terminal illness,” he noted.

“Regardless, it still behooves us to have conversations with our patients and families about what are they willing to go through, and how they define a quality of life,” he said.

Strategies such as those used at the University of Texas show the importance of primary care palliative skill development, said Dr. Ansari. “Every physician should have the skill set of having conversations with patients and families on goals, values, and preferences even in unknown situations,” he said. That lifelong skill set development begins in medical school, he added.

Dr. Johnston and Dr. Ansari had no financial conflicts to disclose.

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Patients dying without their loved ones, families forced to remotely decide goals of care without the physical presence or human connection of the care team, overworked staff physically isolated from their critically ill patients, and at-risk community members with uncertain and undocumented goals for care are among the universal challenges confronted by hospitals and hospitalists during this COVID-19 pandemic. Partnerships among hospital medicine (HM) and palliative care (PC) teams at Dell Medical School/Dell Seton Medical Center thrive on mutually shared core values of patient centered care – compassion, empathy, and humanity.

A key PC-HM collaboration was adapting our multidisciplinary huddle to focus on communication effectiveness and efficiency in the medical intensive care unit (MICU). Expanded interprofessional and cross-specialty collaboration promoted streamlined, succinct, and standardized communication with patients’ families while their loved ones were critically ill with COVID-19. The PC team attended daily MICU multidisciplinary huddles, attentive to both the medical and psychosocial updates for each patient. During huddles, residents or HM providers were asked to end their presentation with a clinical status “headline” and solicited feedback from the multidisciplinary team before messaging to the family. The PC team then communicated with families a succinct and cohesive medical update and continuously explored goals of care. This allowed the HM team, often overwhelmed with admissions, co-managing intensive care patients, and facilitating safe discharges, to focus on urgent issues while PC provided continuity and personalized support for patients and families. PC’s ability to synthesize and summarize clinical information from multiple teams and then provide cohesive updates in patient-friendly language modeled important communication skills for learners and simultaneously benefited HM providers.

Our chaplains, too, were central to facilitating timely, proactive conversations and documentation of Medical Power of Attorney (MPOA) for patients with COVID-19 admitted to our hospital. HM prioritized early admission conversations with patients to counsel them on severity of illness, prognosis based on risk factors, to elucidate wishes for intubation or resuscitation, and to capture their desired medical decision maker. HM was notified of all COVID and PUI admissions, allowing us to speak with even critically ill patients in the ER or ICU prior to intubation in order to quickly and accurately capture patients’ wishes for treatment and delegate decision makers. Our chaplains supported and supplemented these efforts by diligently and dutifully soliciting, hearing, and documenting patient MPOA delegates, with over 50% MPOA completion by 24 hours of hospitalization.

Another early PC-HM project, “Meet My Loved One,” was adapted from the University of Alabama at Birmingham Palliative and Comfort Unit. The absence of families visiting the ICU and sharing pictures, stories, anecdotes of our patients left a deeply felt, dehumanizing void in the halls and rooms of our hospital. To fill this space with life and humanity, furloughed medical students on their “transition of care” electives contacted family members of their “continuity” patients focusing primarily on those patients expected to have prolonged ICU or hospital stays and solicited personal, humanizing information about our patients. Questions included: “What is your loved one’s preferred name or nickname?” and “What are three things we should know to take better care of your loved one?” With family permission, we posted this information on the door outside the patient’s room. Nursing staff, in particular, appreciated getting to know their patients more personally and families appreciated the staff’s desire to know their loved one as an individual.

It is also important to acknowledge setbacks. Early efforts to engage technology proved more foe than friend. We continue to struggle with using our iPads for video visits. Most of our families prefer “WhatsApp” for video communication, which is not compatible with operating systems on early versions of the iPad, which were generously and widely donated by local school systems. Desperate to allow families to connect, many providers resorted to using personal devices to facilitate video visits and family meetings. And we discovered that many video visits caused more not less family angst, especially for critically ill patients. Families often required preparation and coaching on what to expect and how to interact with intubated, sedated, proned, and paralyzed loved ones.

Our hospital medicine and palliative care teams have an established strong partnership. The COVID-19 pandemic created novel communication challenges but our shared mission toward patient-centered care allowed us to effectively collaborate to bring the patients goals of care to the forefront aligning patients, families, physicians, nurses, and staff during the COVID-19 surge.

Dr. Johnston is associate professor at Dell Medical School at The University of Texas in Austin. She practices hospital medicine and inpatient palliative care at Dell Seton Medical Center. Dr. Cooremans is a resident physician at Dell Medical School. Dr. Salib is the internal medicine clerkship director and an associate professor at Dell Medical School. Dr. Nieto is an assistant professor and associate chief of the Division of Hospital Medicine at Dell Medical School. Dr. Patel is an assistant professor at Dell Medical School. This article is part of a series written by members of the Division of Hospital Medicine at Dell Medical School, exploring lessons learned from the coronavirus pandemic and outlining an approach for creating COVID-19 Centers of Excellence. The article first appeared in The Hospital Leader, the official blog of SHM.

Patients dying without their loved ones, families forced to remotely decide goals of care without the physical presence or human connection of the care team, overworked staff physically isolated from their critically ill patients, and at-risk community members with uncertain and undocumented goals for care are among the universal challenges confronted by hospitals and hospitalists during this COVID-19 pandemic. Partnerships among hospital medicine (HM) and palliative care (PC) teams at Dell Medical School/Dell Seton Medical Center thrive on mutually shared core values of patient centered care – compassion, empathy, and humanity.

A key PC-HM collaboration was adapting our multidisciplinary huddle to focus on communication effectiveness and efficiency in the medical intensive care unit (MICU). Expanded interprofessional and cross-specialty collaboration promoted streamlined, succinct, and standardized communication with patients’ families while their loved ones were critically ill with COVID-19. The PC team attended daily MICU multidisciplinary huddles, attentive to both the medical and psychosocial updates for each patient. During huddles, residents or HM providers were asked to end their presentation with a clinical status “headline” and solicited feedback from the multidisciplinary team before messaging to the family. The PC team then communicated with families a succinct and cohesive medical update and continuously explored goals of care. This allowed the HM team, often overwhelmed with admissions, co-managing intensive care patients, and facilitating safe discharges, to focus on urgent issues while PC provided continuity and personalized support for patients and families. PC’s ability to synthesize and summarize clinical information from multiple teams and then provide cohesive updates in patient-friendly language modeled important communication skills for learners and simultaneously benefited HM providers.

Our chaplains, too, were central to facilitating timely, proactive conversations and documentation of Medical Power of Attorney (MPOA) for patients with COVID-19 admitted to our hospital. HM prioritized early admission conversations with patients to counsel them on severity of illness, prognosis based on risk factors, to elucidate wishes for intubation or resuscitation, and to capture their desired medical decision maker. HM was notified of all COVID and PUI admissions, allowing us to speak with even critically ill patients in the ER or ICU prior to intubation in order to quickly and accurately capture patients’ wishes for treatment and delegate decision makers. Our chaplains supported and supplemented these efforts by diligently and dutifully soliciting, hearing, and documenting patient MPOA delegates, with over 50% MPOA completion by 24 hours of hospitalization.

Another early PC-HM project, “Meet My Loved One,” was adapted from the University of Alabama at Birmingham Palliative and Comfort Unit. The absence of families visiting the ICU and sharing pictures, stories, anecdotes of our patients left a deeply felt, dehumanizing void in the halls and rooms of our hospital. To fill this space with life and humanity, furloughed medical students on their “transition of care” electives contacted family members of their “continuity” patients focusing primarily on those patients expected to have prolonged ICU or hospital stays and solicited personal, humanizing information about our patients. Questions included: “What is your loved one’s preferred name or nickname?” and “What are three things we should know to take better care of your loved one?” With family permission, we posted this information on the door outside the patient’s room. Nursing staff, in particular, appreciated getting to know their patients more personally and families appreciated the staff’s desire to know their loved one as an individual.

It is also important to acknowledge setbacks. Early efforts to engage technology proved more foe than friend. We continue to struggle with using our iPads for video visits. Most of our families prefer “WhatsApp” for video communication, which is not compatible with operating systems on early versions of the iPad, which were generously and widely donated by local school systems. Desperate to allow families to connect, many providers resorted to using personal devices to facilitate video visits and family meetings. And we discovered that many video visits caused more not less family angst, especially for critically ill patients. Families often required preparation and coaching on what to expect and how to interact with intubated, sedated, proned, and paralyzed loved ones.

Our hospital medicine and palliative care teams have an established strong partnership. The COVID-19 pandemic created novel communication challenges but our shared mission toward patient-centered care allowed us to effectively collaborate to bring the patients goals of care to the forefront aligning patients, families, physicians, nurses, and staff during the COVID-19 surge.

Dr. Johnston is associate professor at Dell Medical School at The University of Texas in Austin. She practices hospital medicine and inpatient palliative care at Dell Seton Medical Center. Dr. Cooremans is a resident physician at Dell Medical School. Dr. Salib is the internal medicine clerkship director and an associate professor at Dell Medical School. Dr. Nieto is an assistant professor and associate chief of the Division of Hospital Medicine at Dell Medical School. Dr. Patel is an assistant professor at Dell Medical School. This article is part of a series written by members of the Division of Hospital Medicine at Dell Medical School, exploring lessons learned from the coronavirus pandemic and outlining an approach for creating COVID-19 Centers of Excellence. The article first appeared in The Hospital Leader, the official blog of SHM.

Patients dying without their loved ones, families forced to remotely decide goals of care without the physical presence or human connection of the care team, overworked staff physically isolated from their critically ill patients, and at-risk community members with uncertain and undocumented goals for care are among the universal challenges confronted by hospitals and hospitalists during this COVID-19 pandemic. Partnerships among hospital medicine (HM) and palliative care (PC) teams at Dell Medical School/Dell Seton Medical Center thrive on mutually shared core values of patient centered care – compassion, empathy, and humanity.

A key PC-HM collaboration was adapting our multidisciplinary huddle to focus on communication effectiveness and efficiency in the medical intensive care unit (MICU). Expanded interprofessional and cross-specialty collaboration promoted streamlined, succinct, and standardized communication with patients’ families while their loved ones were critically ill with COVID-19. The PC team attended daily MICU multidisciplinary huddles, attentive to both the medical and psychosocial updates for each patient. During huddles, residents or HM providers were asked to end their presentation with a clinical status “headline” and solicited feedback from the multidisciplinary team before messaging to the family. The PC team then communicated with families a succinct and cohesive medical update and continuously explored goals of care. This allowed the HM team, often overwhelmed with admissions, co-managing intensive care patients, and facilitating safe discharges, to focus on urgent issues while PC provided continuity and personalized support for patients and families. PC’s ability to synthesize and summarize clinical information from multiple teams and then provide cohesive updates in patient-friendly language modeled important communication skills for learners and simultaneously benefited HM providers.

Our chaplains, too, were central to facilitating timely, proactive conversations and documentation of Medical Power of Attorney (MPOA) for patients with COVID-19 admitted to our hospital. HM prioritized early admission conversations with patients to counsel them on severity of illness, prognosis based on risk factors, to elucidate wishes for intubation or resuscitation, and to capture their desired medical decision maker. HM was notified of all COVID and PUI admissions, allowing us to speak with even critically ill patients in the ER or ICU prior to intubation in order to quickly and accurately capture patients’ wishes for treatment and delegate decision makers. Our chaplains supported and supplemented these efforts by diligently and dutifully soliciting, hearing, and documenting patient MPOA delegates, with over 50% MPOA completion by 24 hours of hospitalization.

Another early PC-HM project, “Meet My Loved One,” was adapted from the University of Alabama at Birmingham Palliative and Comfort Unit. The absence of families visiting the ICU and sharing pictures, stories, anecdotes of our patients left a deeply felt, dehumanizing void in the halls and rooms of our hospital. To fill this space with life and humanity, furloughed medical students on their “transition of care” electives contacted family members of their “continuity” patients focusing primarily on those patients expected to have prolonged ICU or hospital stays and solicited personal, humanizing information about our patients. Questions included: “What is your loved one’s preferred name or nickname?” and “What are three things we should know to take better care of your loved one?” With family permission, we posted this information on the door outside the patient’s room. Nursing staff, in particular, appreciated getting to know their patients more personally and families appreciated the staff’s desire to know their loved one as an individual.

It is also important to acknowledge setbacks. Early efforts to engage technology proved more foe than friend. We continue to struggle with using our iPads for video visits. Most of our families prefer “WhatsApp” for video communication, which is not compatible with operating systems on early versions of the iPad, which were generously and widely donated by local school systems. Desperate to allow families to connect, many providers resorted to using personal devices to facilitate video visits and family meetings. And we discovered that many video visits caused more not less family angst, especially for critically ill patients. Families often required preparation and coaching on what to expect and how to interact with intubated, sedated, proned, and paralyzed loved ones.

Our hospital medicine and palliative care teams have an established strong partnership. The COVID-19 pandemic created novel communication challenges but our shared mission toward patient-centered care allowed us to effectively collaborate to bring the patients goals of care to the forefront aligning patients, families, physicians, nurses, and staff during the COVID-19 surge.

Dr. Johnston is associate professor at Dell Medical School at The University of Texas in Austin. She practices hospital medicine and inpatient palliative care at Dell Seton Medical Center. Dr. Cooremans is a resident physician at Dell Medical School. Dr. Salib is the internal medicine clerkship director and an associate professor at Dell Medical School. Dr. Nieto is an assistant professor and associate chief of the Division of Hospital Medicine at Dell Medical School. Dr. Patel is an assistant professor at Dell Medical School. This article is part of a series written by members of the Division of Hospital Medicine at Dell Medical School, exploring lessons learned from the coronavirus pandemic and outlining an approach for creating COVID-19 Centers of Excellence. The article first appeared in The Hospital Leader, the official blog of SHM.

Study Overview

Objective. To examine the trend of noninvasive and invasive mechanical ventilation at the end of life from 2000 to 2017.

Design. Observational population-based cohort study.

Setting and participants. The study was a population-based cohort study to examine the use of noninvasive and invasive mechanical ventilation among decedents. The study included a random 20% sample of Medicare beneficiaries older than 65 years who were hospitalized in the last 30 days of life and died between January 1, 2000, and December 31, 2017, except for the period October 1, 2015, to December 31, 2015, when the transition from International Classification of Diseases, Ninth Revision (ICD-9) to ICD-10 occurred. Beneficiaries with the primary admitting diagnosis of cardiac arrest or with preexisting tracheostomy were excluded because of expected requirements for ventilatory support. The sample included a total of 2,470,735 Medicare beneficiaries; mean age was 82.2 years, and 54.8% were female. Primary admitting diagnosis codes were used to identify 3 subcohorts: congestive heart failure, chronic obstructive pulmonary disease, and cancer; a fourth subcohort of dementia was identified using the primary admitting diagnosis code or the first 9 secondary diagnosis codes.

Main outcome measures. The study used procedure codes to identify the use of noninvasive ventilation, invasive mechanical ventilation, or none among decedents who were hospitalized in the last 30 days of life. Descriptive statistics to characterize variables by year of hospitalization and ventilatory support were calculated, and the rates of noninvasive and invasive mechanical ventilation use were tabulated. Other outcomes of interest include site of death (in-hospital death), hospice enrollment at death, and hospice enrollment in the last 3 days of life as measures of end-of- life care use. Multivariable logistic regressions were used to examine noninvasive and invasive mechanical ventilation use among decedents, and time trends were examined, with the pattern of use in year 2000 as reference. Subgroup analysis with the subcohort of patients with different diagnoses were conducted to examine trends.

Main results. From 2000 to 2017, 16.3% of decedents had invasive mechanical ventilation, 3.7% had noninvasive ventilation, and 1.0% had both noninvasive and invasive ventilation during their hospital stay. Compared to the reference year 2000, there was a 9-fold increase in noninvasive ventilation use, from 0.8% to 7.1% in 2017, and invasive mechanical ventilation use also increased slightly, from 15.0% to 18.5%. Compared to year 2000, decedents were 2.63 times and 1.04 times (adjusted odds ratio [OR]) more likely to receive noninvasive ventilation and invasive mechanical ventilation, respectively, in 2005, 7.87 times and 1.39 times more likely in 2011, and 11.84 times and 1.63 times more likely in 2017.

Subgroup analysis showed that for congestive heart failure and chronic obstructive pulmonary disease, the increase in noninvasive ventilation use mirrored the trend observed for the overall population, but the use of invasive mechanical ventilation did not increase from 2000 to 2017, with a rate of use of 11.1% versus 7.8% (adjusted OR, 1.07; 95% confidence interval [CI], 0.95-1.19) for congestive heart failure and 17.4% vs 13.2% (OR 1.03, 95% CI, 0.88-1.21) for chronic obstructive pulmonary disease. For the cancer and dementia subgroups, the increase in noninvasive ventilation use from 2000 to 2017 was accompanied by an increase in the use of invasive mechanical ventilation, with a rate of 6.2% versus 7.4% (OR, 1.40; 95% CI, 1.26-1.55) for decedents with cancer and a rate of 5.7% versus 6.2% (OR, 1.28; 95% CI, 1.17-1.41) for decedents with dementia. For other measures of end-of-life care, noninvasive ventilation use when compared to invasive mechanical ventilation use was associated with lower rates of in-hospital (acute care) deaths (50.3% vs 76.7%), hospice enrollment in the last 3 days of life (late hospice enrollment; 57.7% vs 63.0%), and higher rates of hospice enrollment at death (41.3% vs 20.0%).

Conclusion. There was an increase in the use of noninvasive ventilation from 2000 through 2017 among Medicare beneficiaries who died. The findings also suggest that the use of invasive mechanical ventilation did not increase among decedents with congestive heart failure and chronic obstructive pulmonary disease but increased among decedents with cancer and dementia.

Noninvasive ventilation offers an alternative to invasive mechanical ventilation for providing ventilatory support for respiratory failure, and may offer benefits as it could avert adverse effects associated with invasive mechanical ventilation, particularly in the management of respiratory failure due to congestive heart failure and chronic obstructive pulmonary disease.¹ There is evidence for potential benefits of use of noninvasive ventilation in other clinical scenarios, such as pneumonia in older adults with comorbidities, though its clinical utility is not as well established for other diseases.²

As noninvasive ventilation is introduced into clinical practice, it is not surprising that over the period of the study (2000 to 2017) that its use increased substantially. Advance directives that involve discussion of life-sustaining treatments, including in scenarios with respiratory failure, may also result in physician orders that specify whether an individual desires invasive mechanical ventilation versus other medical treatments, including noninvasive ventilation.^3,4 By examining the temporal trends of use of noninvasive and invasive ventilation, this study reveals that invasive mechanical ventilation use among decedents with dementia and cancer has increased, despite increases in the use of noninvasive ventilation. It is important to understand further what would explain these temporal trends and whether the use of noninvasive and also invasive mechanical ventilation at the end of life represents appropriate care with clear goals or whether it may represent overuse. It is also less clear in the end-of-life care scenario what the goals of treatment with noninvasive ventilation would be, especially if it does not avert the use of invasive mechanical ventilation.

The study includes decedents only, thus limiting the ability to draw conclusions about clinically appropriate care.⁵ Further studies should examine a cohort of patients who have serious and life-threatening illness to examine the trends and potential effects of noninvasive ventilation on outcomes and utilization, as individuals who have improved and survived would not be included in this present decedent cohort.

Applications for Clinical Practice

This study highlights changes in the use of noninvasive and invasive ventilation over time and the different trends seen among subgroups with different diagnoses. For older adults with serious comorbid illness such as dementia, it is especially important to have discussions on advance directives so that care at the end of life is concordant with the patient’s wishes and that unnecessary, burdensome care can be averted. Further studies to understand and define the appropriate use of noninvasive and invasive mechanical ventilation for older adults with significant comorbidities who have serious, life-threatening illness are needed to ensure appropriate clinical treatment at the end of life.

–William W. Hung, MD, MPH

Study Overview

Objective. To examine the trend of noninvasive and invasive mechanical ventilation at the end of life from 2000 to 2017.

Design. Observational population-based cohort study.

Setting and participants. The study was a population-based cohort study to examine the use of noninvasive and invasive mechanical ventilation among decedents. The study included a random 20% sample of Medicare beneficiaries older than 65 years who were hospitalized in the last 30 days of life and died between January 1, 2000, and December 31, 2017, except for the period October 1, 2015, to December 31, 2015, when the transition from International Classification of Diseases, Ninth Revision (ICD-9) to ICD-10 occurred. Beneficiaries with the primary admitting diagnosis of cardiac arrest or with preexisting tracheostomy were excluded because of expected requirements for ventilatory support. The sample included a total of 2,470,735 Medicare beneficiaries; mean age was 82.2 years, and 54.8% were female. Primary admitting diagnosis codes were used to identify 3 subcohorts: congestive heart failure, chronic obstructive pulmonary disease, and cancer; a fourth subcohort of dementia was identified using the primary admitting diagnosis code or the first 9 secondary diagnosis codes.

Main outcome measures. The study used procedure codes to identify the use of noninvasive ventilation, invasive mechanical ventilation, or none among decedents who were hospitalized in the last 30 days of life. Descriptive statistics to characterize variables by year of hospitalization and ventilatory support were calculated, and the rates of noninvasive and invasive mechanical ventilation use were tabulated. Other outcomes of interest include site of death (in-hospital death), hospice enrollment at death, and hospice enrollment in the last 3 days of life as measures of end-of- life care use. Multivariable logistic regressions were used to examine noninvasive and invasive mechanical ventilation use among decedents, and time trends were examined, with the pattern of use in year 2000 as reference. Subgroup analysis with the subcohort of patients with different diagnoses were conducted to examine trends.

Main results. From 2000 to 2017, 16.3% of decedents had invasive mechanical ventilation, 3.7% had noninvasive ventilation, and 1.0% had both noninvasive and invasive ventilation during their hospital stay. Compared to the reference year 2000, there was a 9-fold increase in noninvasive ventilation use, from 0.8% to 7.1% in 2017, and invasive mechanical ventilation use also increased slightly, from 15.0% to 18.5%. Compared to year 2000, decedents were 2.63 times and 1.04 times (adjusted odds ratio [OR]) more likely to receive noninvasive ventilation and invasive mechanical ventilation, respectively, in 2005, 7.87 times and 1.39 times more likely in 2011, and 11.84 times and 1.63 times more likely in 2017.

Subgroup analysis showed that for congestive heart failure and chronic obstructive pulmonary disease, the increase in noninvasive ventilation use mirrored the trend observed for the overall population, but the use of invasive mechanical ventilation did not increase from 2000 to 2017, with a rate of use of 11.1% versus 7.8% (adjusted OR, 1.07; 95% confidence interval [CI], 0.95-1.19) for congestive heart failure and 17.4% vs 13.2% (OR 1.03, 95% CI, 0.88-1.21) for chronic obstructive pulmonary disease. For the cancer and dementia subgroups, the increase in noninvasive ventilation use from 2000 to 2017 was accompanied by an increase in the use of invasive mechanical ventilation, with a rate of 6.2% versus 7.4% (OR, 1.40; 95% CI, 1.26-1.55) for decedents with cancer and a rate of 5.7% versus 6.2% (OR, 1.28; 95% CI, 1.17-1.41) for decedents with dementia. For other measures of end-of-life care, noninvasive ventilation use when compared to invasive mechanical ventilation use was associated with lower rates of in-hospital (acute care) deaths (50.3% vs 76.7%), hospice enrollment in the last 3 days of life (late hospice enrollment; 57.7% vs 63.0%), and higher rates of hospice enrollment at death (41.3% vs 20.0%).

Conclusion. There was an increase in the use of noninvasive ventilation from 2000 through 2017 among Medicare beneficiaries who died. The findings also suggest that the use of invasive mechanical ventilation did not increase among decedents with congestive heart failure and chronic obstructive pulmonary disease but increased among decedents with cancer and dementia.

Noninvasive ventilation offers an alternative to invasive mechanical ventilation for providing ventilatory support for respiratory failure, and may offer benefits as it could avert adverse effects associated with invasive mechanical ventilation, particularly in the management of respiratory failure due to congestive heart failure and chronic obstructive pulmonary disease.¹ There is evidence for potential benefits of use of noninvasive ventilation in other clinical scenarios, such as pneumonia in older adults with comorbidities, though its clinical utility is not as well established for other diseases.²

As noninvasive ventilation is introduced into clinical practice, it is not surprising that over the period of the study (2000 to 2017) that its use increased substantially. Advance directives that involve discussion of life-sustaining treatments, including in scenarios with respiratory failure, may also result in physician orders that specify whether an individual desires invasive mechanical ventilation versus other medical treatments, including noninvasive ventilation.^3,4 By examining the temporal trends of use of noninvasive and invasive ventilation, this study reveals that invasive mechanical ventilation use among decedents with dementia and cancer has increased, despite increases in the use of noninvasive ventilation. It is important to understand further what would explain these temporal trends and whether the use of noninvasive and also invasive mechanical ventilation at the end of life represents appropriate care with clear goals or whether it may represent overuse. It is also less clear in the end-of-life care scenario what the goals of treatment with noninvasive ventilation would be, especially if it does not avert the use of invasive mechanical ventilation.

The study includes decedents only, thus limiting the ability to draw conclusions about clinically appropriate care.⁵ Further studies should examine a cohort of patients who have serious and life-threatening illness to examine the trends and potential effects of noninvasive ventilation on outcomes and utilization, as individuals who have improved and survived would not be included in this present decedent cohort.

Applications for Clinical Practice

This study highlights changes in the use of noninvasive and invasive ventilation over time and the different trends seen among subgroups with different diagnoses. For older adults with serious comorbid illness such as dementia, it is especially important to have discussions on advance directives so that care at the end of life is concordant with the patient’s wishes and that unnecessary, burdensome care can be averted. Further studies to understand and define the appropriate use of noninvasive and invasive mechanical ventilation for older adults with significant comorbidities who have serious, life-threatening illness are needed to ensure appropriate clinical treatment at the end of life.

–William W. Hung, MD, MPH

Study Overview

Objective. To examine the trend of noninvasive and invasive mechanical ventilation at the end of life from 2000 to 2017.

Design. Observational population-based cohort study.

Setting and participants. The study was a population-based cohort study to examine the use of noninvasive and invasive mechanical ventilation among decedents. The study included a random 20% sample of Medicare beneficiaries older than 65 years who were hospitalized in the last 30 days of life and died between January 1, 2000, and December 31, 2017, except for the period October 1, 2015, to December 31, 2015, when the transition from International Classification of Diseases, Ninth Revision (ICD-9) to ICD-10 occurred. Beneficiaries with the primary admitting diagnosis of cardiac arrest or with preexisting tracheostomy were excluded because of expected requirements for ventilatory support. The sample included a total of 2,470,735 Medicare beneficiaries; mean age was 82.2 years, and 54.8% were female. Primary admitting diagnosis codes were used to identify 3 subcohorts: congestive heart failure, chronic obstructive pulmonary disease, and cancer; a fourth subcohort of dementia was identified using the primary admitting diagnosis code or the first 9 secondary diagnosis codes.

Main outcome measures. The study used procedure codes to identify the use of noninvasive ventilation, invasive mechanical ventilation, or none among decedents who were hospitalized in the last 30 days of life. Descriptive statistics to characterize variables by year of hospitalization and ventilatory support were calculated, and the rates of noninvasive and invasive mechanical ventilation use were tabulated. Other outcomes of interest include site of death (in-hospital death), hospice enrollment at death, and hospice enrollment in the last 3 days of life as measures of end-of- life care use. Multivariable logistic regressions were used to examine noninvasive and invasive mechanical ventilation use among decedents, and time trends were examined, with the pattern of use in year 2000 as reference. Subgroup analysis with the subcohort of patients with different diagnoses were conducted to examine trends.

Main results. From 2000 to 2017, 16.3% of decedents had invasive mechanical ventilation, 3.7% had noninvasive ventilation, and 1.0% had both noninvasive and invasive ventilation during their hospital stay. Compared to the reference year 2000, there was a 9-fold increase in noninvasive ventilation use, from 0.8% to 7.1% in 2017, and invasive mechanical ventilation use also increased slightly, from 15.0% to 18.5%. Compared to year 2000, decedents were 2.63 times and 1.04 times (adjusted odds ratio [OR]) more likely to receive noninvasive ventilation and invasive mechanical ventilation, respectively, in 2005, 7.87 times and 1.39 times more likely in 2011, and 11.84 times and 1.63 times more likely in 2017.

Subgroup analysis showed that for congestive heart failure and chronic obstructive pulmonary disease, the increase in noninvasive ventilation use mirrored the trend observed for the overall population, but the use of invasive mechanical ventilation did not increase from 2000 to 2017, with a rate of use of 11.1% versus 7.8% (adjusted OR, 1.07; 95% confidence interval [CI], 0.95-1.19) for congestive heart failure and 17.4% vs 13.2% (OR 1.03, 95% CI, 0.88-1.21) for chronic obstructive pulmonary disease. For the cancer and dementia subgroups, the increase in noninvasive ventilation use from 2000 to 2017 was accompanied by an increase in the use of invasive mechanical ventilation, with a rate of 6.2% versus 7.4% (OR, 1.40; 95% CI, 1.26-1.55) for decedents with cancer and a rate of 5.7% versus 6.2% (OR, 1.28; 95% CI, 1.17-1.41) for decedents with dementia. For other measures of end-of-life care, noninvasive ventilation use when compared to invasive mechanical ventilation use was associated with lower rates of in-hospital (acute care) deaths (50.3% vs 76.7%), hospice enrollment in the last 3 days of life (late hospice enrollment; 57.7% vs 63.0%), and higher rates of hospice enrollment at death (41.3% vs 20.0%).

Conclusion. There was an increase in the use of noninvasive ventilation from 2000 through 2017 among Medicare beneficiaries who died. The findings also suggest that the use of invasive mechanical ventilation did not increase among decedents with congestive heart failure and chronic obstructive pulmonary disease but increased among decedents with cancer and dementia.

Noninvasive ventilation offers an alternative to invasive mechanical ventilation for providing ventilatory support for respiratory failure, and may offer benefits as it could avert adverse effects associated with invasive mechanical ventilation, particularly in the management of respiratory failure due to congestive heart failure and chronic obstructive pulmonary disease.¹ There is evidence for potential benefits of use of noninvasive ventilation in other clinical scenarios, such as pneumonia in older adults with comorbidities, though its clinical utility is not as well established for other diseases.²

As noninvasive ventilation is introduced into clinical practice, it is not surprising that over the period of the study (2000 to 2017) that its use increased substantially. Advance directives that involve discussion of life-sustaining treatments, including in scenarios with respiratory failure, may also result in physician orders that specify whether an individual desires invasive mechanical ventilation versus other medical treatments, including noninvasive ventilation.^3,4 By examining the temporal trends of use of noninvasive and invasive ventilation, this study reveals that invasive mechanical ventilation use among decedents with dementia and cancer has increased, despite increases in the use of noninvasive ventilation. It is important to understand further what would explain these temporal trends and whether the use of noninvasive and also invasive mechanical ventilation at the end of life represents appropriate care with clear goals or whether it may represent overuse. It is also less clear in the end-of-life care scenario what the goals of treatment with noninvasive ventilation would be, especially if it does not avert the use of invasive mechanical ventilation.

The study includes decedents only, thus limiting the ability to draw conclusions about clinically appropriate care.⁵ Further studies should examine a cohort of patients who have serious and life-threatening illness to examine the trends and potential effects of noninvasive ventilation on outcomes and utilization, as individuals who have improved and survived would not be included in this present decedent cohort.

Applications for Clinical Practice

This study highlights changes in the use of noninvasive and invasive ventilation over time and the different trends seen among subgroups with different diagnoses. For older adults with serious comorbid illness such as dementia, it is especially important to have discussions on advance directives so that care at the end of life is concordant with the patient’s wishes and that unnecessary, burdensome care can be averted. Further studies to understand and define the appropriate use of noninvasive and invasive mechanical ventilation for older adults with significant comorbidities who have serious, life-threatening illness are needed to ensure appropriate clinical treatment at the end of life.

–William W. Hung, MD, MPH