American Journal of Hospice and Palliative Medicine®

Hospice-eligible patients are vulnerable to adverse medication effects given their advanced illnesses and general older age. It is not known how often medications are not renal dose adjusted in hospice-eligible patients and which are frequently problematic. This study aims to identify commonly prescribed medications with significant renal clearance that are dosed too high and patient characteristics that increase the likelihood of occurrence.

This is a retrospective chart review of adult patients admitted to hospice care. Data collected included clinical/demographic data, renally cleared medications taken at time of hospice admission, and calculated renal function using several formulas. Descriptive statistics and binomial logistic regression were used to analyze data.

Of 283 included charts, 27% had ≥1 medication dosed too high for renal function. The most common medications prescribed and not renal dose adjusted included tramadol, gabapentin, duloxetine, loratadine, cetirizine, famotidine, apixaban, rivaroxaban, metformin, trospium, and most antimicrobials. Increasing serum creatinine values and increasing number of renally cleared medications were associated with a higher likelihood of a medication dosed too high [OR, 1.702, 95% CI (1.257, 2.305), P < 0.001] and [OR, 1.856, 95% CI (1.517, 2.271), P < 0.001] respectively. Residing at home vs a facility was associated with a reduced likelihood of having a medication dosed too high [OR, 0.30, 95% CI (0.134, 0.673), P = 0.003.].

Hospice-eligible patients frequently have renally cleared medications prescribed and at doses too high for their renal function. Analgesics, over-the-counter antihistamines, anticoagulants, anticholinergics have potential for significant adverse effects and higher vigilance is needed.

Many severe COPD patients are unaware of their treatment options and lack motivation for advance care planning. It is crucial to increase patient awareness regarding their chronic conditions.

The InformedTogether decision aid was used in outpatient clinical visits to inform patients about their COPD prognosis. Audio-recorded visits were analyzed for how denial, self-perceived health, and trust impacted patient motivation to make an advance care plan.

Of the 26 patients, 4 (15.38%) showed an increase in motivation, 20 (76.92%) had no change, and 2 (7.69%) showed a decrease in motivation. Denial facilitated by physicians did not significantly affect motivation (p = 0.543). Self-perceived health also had no significant impact on motivation, with 68.00% rating their health as poor, 16.00% as fair, and 16.00% as good (p = 0.847). Trust in the physician’s information was generally high, with 64.00% reporting high trust, but did not lead to an increase in motivation (p = 0.512).

Denial, self-perceived health, and trust did not significantly affect patient motivation to make an advance care plan. This study suggests that barriers to increasing motivation remain, and further research on external factors may be helpful to improve patient participation in end-of-life care planning.

American Indian/Alaska Native (AI/AN) persons disproportionately suffer from end-stage kidney disease caused by diabetes (ESKD-D). Kidney transplant is the most desirable option to treating ESKD-D, but remains unattainable for many AI/AN persons, especially in rural South Dakota (SD). Additionally, palliative and hospice care options for AI/AN with any serious illness in SD are largely inaccessible. Moreover, receiving kidney transplant potentially affects hospice referral because of the desire to prolong transplant function. Therefore, the purpose of this study was to compare hospice use rates among AI/AN and non-Hispanic White (NHW) persons with ESKD-D prior to death and determine if differences in referral rates are present for those with and without a prior kidney transplant.

Retrospective cohort analysis of United States Renal Data System data from 2000-2021. Data for persons with hospice care, transplant status, place of death, and race were analyzed using chi-squared tests with Yates’ continuity correction and the Cochran-Mantel-Haenszel test.

AI/AN persons with ESKD-D were less likely to receive hospice care prior to death compared to NHW persons in both transplant (P < 0.001) and non-transplant (P < 0.001) groups. When comparing transplant and non-transplant groups by hospice use, persons with no previous transplant were more likely to receive hospice care prior to death (P < 0.001).

These results confirm the assumptions of significant differences in hospice care use among AI/AN vs NHW who have ESKD-D, including differences between those with a prior transplant. There is a need to expand palliative/hospice care services for persons with a prior kidney transplant.

End-of-life doulas (EOLDs) offer non-medical support to patients and families, yet little is known regarding how knowledgeable and receptive gynecologic oncologists are to EOLDs.

Members of the New England Association of Gynecologic Oncologists (NEAGO) were surveyed regarding demographics and familiarity with and attitudes towards EOLDs. Descriptive statistics described demographics. Chi-square testing and Spearman’s correlation coefficient were used for comparative analysis.

Thirty-nine of 85 NEAGO members completed the survey (response rate 46%). Most were physician gynecologic oncologists (95%) who practiced in academic settings (79%) and participated in end-of-life care (92%). Thirty-nine percent had heard of an EOLD. One clinician had a patient or family request EOLD services, but no one had personally worked with an EOLD. No one was familiar with the cost of EOLDs. After reading information regarding EOLDs, most agreed that EOLDs could be a valuable component of end-of-life care (87%) and they should be accessible and affordable to patients (85%). A majority reported they would be likely to recommend an EOLD to patients during the dying period (62%). A positive correlation was found between those who perceived EOLDs as valuable and their likelihood to recommend EOLDs to patients (r_s = 0.6, P < 0.001). Younger clinicians and those with fewer years of practice were also more likely to recommend EOLDs to patients.

Knowledge of and experience with EOLDs is limited among surveyed gynecologic oncologists. After education on their roles, many clinicians see value in their services and would recommend EOLDs to their patients.

Moral distress (MD), the notion of not being permitted to act in a morally and ethically correct manner, is evident amongst oncologists caring for terminally ill patients. Oncologists often contend with complex decisions, such as withholding treatment and managing family distress. Sociocultural and individual considerations also influence an oncologist’s perception of MD, which can vary in severity due to changing ethical, practical, clinical, moral and professional considerations and shifting contextual circumstances. Their impact compromises an oncologist’s wellbeing, patient outcomes and care of their family. Recent data suggests long-term consequences to MD and alludes to a broader cost of caring that encompasses compassion fatigue, vicarious trauma, secondary traumatic stress and burnout.

This study aims to determine how oncologists in Singapore experience MD and the costs of caring through secondary analysis of interviews with 12 oncologists.

Analysis of the interview transcripts revealed the following domains: 1) sources of MD; 2) sources of the costs of caring; and 3) protective factors.

This secondary analysis of Singaporean oncologists suggests that MD is not frequently an isolated experience; rather, it leads to growing distress amongst oncologists—contributing to a wider cost of caring. This then impacts oncologists’ decisioning, actions, practice and career trajectories. Longitudinal structured training, establishing personalised support for all oncologists and creating a safe working environment supported by the host organisation are thus critical to ensure sustainable practice.

Intensive end-of-life (EOL) care is emotionally and financially burdensome, disproportionally negatively impacting racial and ethnic minorities, rural residents, and lower socioeconomic seniors.

To evaluate the impact of race, ethnicity, and rural residency on EOL Intensive Care Unit (ICU) stays, emergency department (ED) visits, 30-day readmissions, and Advanced Care Planning (ACP) in Colorado residents when controlling for comorbidities.

This retrospective cohort study analyzed data from the Colorado All-Payer Claims Database for 92,975 severely or chronically ill individuals (2018-2021). It used logistic regression models to evaluate associations between demographic variables and EOL health care utilization outcomes.

ICU Stays: Hispanic/Latino, Asian, and Black members had increased ICU stays compared to Whites (Adj. OR: 1.24;1.34;1.28: 95% CI). However, members without ACP and rural residents had lower ICU stays (Adj. OR: 0.67; 0.89: 95% CI). ED Visits: Hispanic/Latino, Asian, Black members, non-dually eligible members (Medicare Fee for Service (MFFS) + Medicaid), and rural residents had increased ED visits (Adj. OR: 1.29; 1.39; 1.19; 1.17; 2.04: 95% CI). Meanwhile, members without ACP or hospice care had lower ED visits (Adj. OR: 0.70; 0.75: 95% CI). 30-day Readmissions: Asian members and rural residents had increased 30-day readmissions (Adjusted OR: 2.42; 1.06: 95% CI). In contrast, those on MFFS and not on Medicaid, members without ACP, and those not in hospice care had decreased 30-day readmissions (Adj. OR: 0.69; 0.47; 0.83: 95% CI).

EOL racial, geographic, and socioeconomic disparities exist in Colorado, requiring urgent interventions for a more equitable health care system.

While advance care planning (ACP) can facilitate a “good death” for people living with cancer, there remain gaps in understanding how to optimize ACP for better patient outcomes. This formative research aimed to explore experiences with advance care planning among oncology and primary care practitioners in primary/tertiary care settings.

The research team conducted structured and semi-structured in-depth interviews with family medicine practitioners (n = 12) and medical oncologists (n = 12) to understand their approaches to ACP.

While oncologists and PCPs shared many of the same concerns about advance care planning, their unique contexts and specialties influenced their perspectives on the approach to ACP. Though oncologists and PCPs were both very likely to discuss ACP with their patients, oncologists more often discussed conducting ACP with other members of the health care team (e.g. social workers). Furthermore, disciplines differed in their emphasis on particular types of ACP documentation. Semi-structured interviews also revealed issues related to provider-patient communication as well as institutional challenges. Participants discussed their processes for timing the ACP conversation, addressing language-use challenges, assessing patient goals, and ensuring a good ACP workflow.

Participants recommended areas for institutional support and intervention to improve provider-patient ACP interactions.

Readmissions and death for palliative care patients are common and costly outcomes for hospitals, patients, and/or caregivers. Predicting which patients are likely to be readmitted or die within 30 days would help allocate resources and aid in patient disposition planning. Few factors have been strongly correlated with predicting which patients will be readmitted or die within 30 days of hospital discharge. The LACE (Length of Stay, Acuity of admission, Charlson comorbidity index, Emergency department use) score has been validated in medical/surgical patients; however, it has not been evaluated in the palliative care population.

To evaluate the LACE score in palliative care population.

This study was a single-center retrospective cohort design.

Patients were identified based on their consultation to an inpatient palliative care service.

Thirty-day readmissions, 30-day mortality, length of stay, acuity of admission, Charlson comorbidity index, emergency department utilization, and demographic information.

The LACE score was not an accurate predictor of clinical outcomes in the palliative care population. Patients who were readmitted or died within 30 days tended to be younger. Patients who were readmitted within 30 days tended to have increased emergency department use in the previous 6 months.

Our study demonstrates the LACE score may not be a sensitive predictor of clinical outcomes in our institution’s palliative care patients. This may be due to the complexity of the required care in this population; thus, other factors should be investigated to determine accurate predictors of patient outcomes to better allocate resources.