Abstract
Letters to the Editor
Study focusing on hospitalization status as a prognostic factor in patients with acute myeloid leukemia. (page 1424)
Brief Reports
The key elements and components of webside manner skills are proper set up, acquainting the participant, maintaining conversation rhythm, responding to emotion, and closing the visit. (page 1507)
Fast Facts and Concepts
Time-Limited Trials for Serious Illness #401 (page 1540)
Aromatase Inhibitor Associated Musculoskeletal Symptoms #402 (page 1542)
Personal Reflection
Perplexed, I reached in my pocket and put on my glasses, just long enough to make out the woman who knew so much about me… I knew her. Not her personally that I could recall, but she was the type of patient with whom I would quickly form a family-like bond as one of the only black physicians she encountered. (page 1547)
Case Discussions in Palliative Medicine
Case of a 15-year-old female with terminal glioblastoma who experienced two distinct end-of-life dreams/visions. (page 1549)
Book and Media Reviews
(page 1553)
Recent Literature
(page 1555)
Hospital Deaths without Palliative Care
A retrospective cross-sectional analysis, using electronic medical records of a state-wide health care system in the U.S. State of Colorado (population 6 million) of adults who died during admission or within seven days of discharge from January 2015 to October 2018 at an academic medical center and had prior encounters within the affiliated state-wide health care system in the last year of life, was performed. Eighty-one percent (n = 2088 deaths) occurred in the hospital. Only 33% of patients had palliative care consultation, which was higher for patients with cancer (42%) than those without cancer (26%). Of patients with specialty palliative care consultation, the median time from first referral to death was eight days (interquartile range 3.25–25 days). With a growing interest in 30-day mortality rates as a quality measure with which to compare hospitals and health systems, the pressure to improve timely hospice and palliative care access will grow. (page 1485)
Medical Assistance in Dying in Canada
Medical assistance in dying (MAID) became legal in Canada in 2016. An exploratory qualitative study to inform quality improvement approaches in the nation's 10 provinces was performed. Patients, families, and health care professionals highlighted access and delivery concerns regarding program sustainability, care pathway ambiguity, lack of support for care choices, institutional conscientious objection, navigating care in institutions with a conscientious objection, and postdeath documentation. Patients and families expressed additional concerns regarding lack of ability to provide advanced MAID consent, and the requirement of independent witnesses on MAID request forms and consent immediately before MAID administration. Health care professionals were additionally uncertain about professional roles and responsibilities. Ten recommendations to improve regional MAID care and the resultant practice change are presented. (page 1468)
Congruence on Desired Place of Death
Congruence between preferred and actual circumstances of palliative care is the “Holy Grail” of quality measures in need of development. In this longitudinal prospective cohort study, the overall congruence between preferred and actual place of death was 72%. Home was the most preferred place of death. The intensity of home-based nursing visits and hours of care from personal support workers increased the likelihood of achieving death in a preferred setting. Is this good enough? Not for most health quality measures. But the methodology and direction and elements of quality improvement are established. (page 1460)
Triggers for Serious Illness Conversations
After internal medicine hospitalist physicians, nurse practitioners, and physician's assistants received training in serious illness conversations, hospitalists on intervention units received verbal notification when their recently admitted patients were identified using a computer algorithm as having possible unmet palliative needs. Hospitalists on the control unit received no notifications. Routinely informing hospitalists when their patients were identified as being at increased risk for unmet palliative needs did not increase the sense of meaning these providers achieved. In contrast, patients in the intervention arm reported improved quality of communication and fewer anxiety and depression symptoms compared with the control patients. Hospice utilization in addition to emergency department visits and hospital readmissions did not differ between the two groups. (page 1500)
Frequent Users of Health Care and a Supportive Care Program
Ohana Health Plan, Inc. (OHP) is one of the first managed care organizations offering supportive care services targeted to frequent users of health care. Bristol Hospice Hawaii, Inc., partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Over 12 months, 27 super-utilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. The mean age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice after supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.005), and shortness of breath (p = 0.04). There was an 80% reduction of emergency department visits per 1000 members and a 75% reduction of hospitalizations per 1000 members. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. (page 1444)