In this Issue

Letters to the Editor

Development of a survey to determine dexamethasone prophylaxis practice when treating bone metastases with radiotherapy, and to explore the factors influencing oncologists' choices. (page 965)

Brief Reports

Observational comparative prospective study on delirium in patients with advanced cancer in different palliative care settings, assessing the presentation/evolution of delirium phenomenology with the Memorial delirium assessment scale. (page 1061)

Fast Facts and Concepts

Total Pain #417 (page 1100)

Mood Disturbances Associated with Long-Term Opioid Therapy #418 (page 1102)

Personal Reflection

The family was resolute in its decision. The affected twin was discharged home with his attentive family and hospice care, anticipating clinical decline when his patent ductus arteriosus closed. I had the honor of seeing him on a home hospice visit before he comfortably died more than two months later surrounded by his family. (page 1107)

Case Discussions in Palliative Medicine

By highlighting how sexuality and palliative care intersect, we hope to foster a community of interdisciplinary palliative care providers who practice what we have termed sex-positive palliative care. (page 1111)

Book and Media Reviews

(page 1117)

Project ECHO: Pediatric Palliative Care

Professional development of health care professionals in pediatric palliative care is a challenge. Project ECHO^® is a model for delivering technology-enabled interprofessional education and cultivating a community of practice. Twenty-four TeleECHO sessions were completed with a mean of 32 ± 12.5 attendees. Acceptability scores (n = 43) ranged from 5.1 ± 1.1 to 6.5 ± 0.6. Health care providers (HCPs) reported improvements in knowledge and self-efficacy across most topics (11 out of 12) and skills (8 out of 10) with demonstrated statistical significance (p-values <0.05). Most participants reported positive practice impacts, including enhanced ability to provide pediatric palliative care (PPC) in their practice. (page 1036)

Medical Assistance in Dying

Medical assistance in dying (MAiD) was enabled in Canada on June 17, 2016. In this retrospective cohort study of 383 patients in Nova Scotia who requested MAiD, a smaller proportion of patients who completed MAiD were seen in consultation by specialist palliative care (69% vs. 81%, p = 0.01). Specialist palliative care was associated with decreased odds of completing MAiD (odds ratio 0.6, p = 0.04). These findings support a more integrated approach to co-ordination of specialist palliative care and MAiD services. (page 1011)

Subcutaneous Levetiracetam for Seizures

A retrospective audit of the use of subcutaneous levetiracetam for inpatients at Sir Michael Sobell House identified. Oral to subcutaneous conversion ratios was 1:1 in all but one case where the dose had to be reduced to fit the syringe driver. Levetiracetam was not mixed with other medications, but administered alone using water for injection as the diluent. No site reactions were reported. In combined analysis of the 139 total cases of subcutaneous levetiracetam administered, efficacy is supported. (page 976)

Deprescribing

In this single-center retrospective chart review of patients cared for in the home setting by a specialty palliative care program, 80 patients with palliative performance scale (PPS) ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death were studied. Deprescribing occurred in 44% within 60 days. Median number of discontinued medications was 3. There was considerable variability between individual physicians. (page 1030)

Public Hospital Palliative Care Clinics

In this survey of California public hospitals, 12 of 15 programs responded; 10 clinics met inclusion criteria. All 10 programs use multiple disciplines to deliver care. Average full-time equivalent used to staff an average of 2.75 half-day clinics per week includes 0.7 physician, 0.5 nurse practitioner, 1.7 nurse, 0.8 social worker, and 0.5 chaplain. Clinic session schedules include an average of two new patient appointment slots (standard deviation [SD] = 0.44) and four follow-up appointment slots (SD = 1.95). The nine programs that reported on clinic volumes see 1081 patients annually combined, with an annual average of 120 (SD = 48.53) per program. Encounters per patient averaged 3 (SD = 1.59; eight programs reporting). All reported offering seven core palliative care (PC) services: pain/symptom management, comprehensive assessment, care co-ordination, advance care planning, palliative care plan of care, emotional support, and social service referrals. An average of 78% (SD = 26%) of clinic financing came from the health systems. (page 1045)