Abstract
Letters to the Editor
Anecdotally, hospital administrators and palliative care leaders say they struggle to get the information needed for planning and evaluating inpatient and ambulatory programs. To determine whether this was the case, we conducted a survey of palliative care programs. (page 4)
Brief Reports
A study to estimate the spending avoided if, by 2022, over 100,000 Californians per year received community-based palliative care (CBPC). We estimated the six-month per patient spending avoided through three mature CBPC programs in California and extrapolated to predict the total avoided spending statewide over eight years if enrollment in the three programs proceeded according to our model. (page 91)
Fast Facts and Concepts
Palliative Care Consultation in the Emergency Department #298 (page 108)
Management of Sialorrhea in ALS #299 (page 110)
Personal Reflection
It is not surprising that many physicians are uncomfortable discussing goals of care and end-of-life realities. The literature supports that approaching and managing these discussions is a learned skill that improves with specific training and education. Unfortunately, the literature also indicates that physicians receive little to no formal training and education on the subject. I believe that this is particularly true in surgical specialties. (page 112)
Book and Media Reviews
(page 118)
Recent Literature
(page 120)
Impact of Community-Based Specialty Care
In this retrospective cohort study, patients who were exposed to community-based palliative care specialists used significantly more home care services and fewer hospital days (p < 0.001) than a propensity matched, unexposed group. On the last day of life, 18% of patients in the exposed group died in an inpatient hospital bed compared to 29% in usual care. (page 16)
Early versus Late Palliative Care
Michael Rabow and colleagues reviewed the care of 922 decedents at a comprehensive cancer center, and found 32% had palliative care referrals. Patients with early palliative care referrals had lower rates of inpatient, ICU and ED utilization in the last month of life. Direct costs of inpatient care in the last six months of life for patients with early palliative care were lower compared to late palliative care ($19,067 versus $25,754, p < 0.01). Early palliative care occurred predominantly in the outpatient setting, while late referrals were mostly made in the hospital. (page 69)
Cultural Differences in Parental Grief
In semistructured interviews, Spanish- and English-speaking parents shared their intense grief associated with the loss of a child but described their hospice experiences in different ways. (page 30)
Patient Selection for Palliative Surgery
The authors identified evidence-based criteria for selecting patients with advanced cancer who might benefit from palliative surgery. (page 22)
Survival and Intensity of Care
Among more than 1800 patients with metastatic lung and colorectal cancer, longer survival was associated with increased intensity of chemotherapy and acute hospital care. Hospice utilization was uniformly low, and most hospice enrollees were referred to hospice in the last 30 days of life. (page 42)
Defining Competencies
The authors describe a consensus-based workshop that created core competences in palliative care for medical and nursing schools in Colombia. (page 76)
Integrating Palliative Care
In this study of phased integration of palliative care, outpatient referrals within three months of death improved end-of-life care for patients and reduced costs, but these benefits were not seen with inpatient palliative care only. Many patients were never referred at all, and the authors call for systematic identification of patients for specialty palliative care. (page 57)
Choosing Hospitalization at the End of Life
Researchers interviewed hospice team members to understand their perceptions about why patients choose hospitalization at the end of life. The themes included not fully understanding hospice, lack of clarity about disease prognosis, desire to continue receiving care from nonhospice physicians and hospital, caregiver burden, distressing/difficult to manage signs and symptoms, caregivers' reluctance to administer morphine, 911's faster response time compared to hospice, and families' difficulty accepting patients' mortality. (page 51)