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Background In response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. Intervention We developed a three-part generalist palliative care program that focuses on ( 1 ) instructional design, ( 2 ) advance care planning, and ( 3 ) engagement. Measures The impact of the program was measured with process measures related to its’ three parts. Outcomes Over four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90-150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over 2 months, 464 interprofessional clinicians documented 5,168 conversations with patients. Conclusion/Lessons Learned A broad based strategy resulted wide institutional engagement with serious illness care.

Background: Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population. Patients and Methods: Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization. Results: The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21–7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10–14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms. Conclusions: This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories. ClinicalTrials.gov identifier: NCT02730858

Attunement, the process of understanding and responding to another's spoken and unspoken needs, is a fundamental concept of human development and the basis of meaningful relationships. To specialize the concept of attunement for palliative care, this article introduces clinical attunement. This term accounts for how palliative care clinicians must repeatedly balance patients' readiness to talk about the future with the cadence of the illness and need for medical decision making. Using the case of Gloria, an example patient living with cancer, this article discusses three skills to foster clinical attunement: asking, repairing disconnections, and offering containment. It is the fourth in a series exploring the psychological elements of palliative care.

Establishing an empathic clinical relationship is a cornerstone of high-quality palliative care. More than simply approaching patients with a pleasant affect or "being nice," we propose that skilled clinicians routinely employ distinct psychological elements when creating effective bonds with seriously ill patients and their families. Palliative care involvement has been shown to improve a variety of outcomes for patients with serious cancer, and yet the components of this salutary effect are still becoming known in the literature. Many believe that a successful interpersonal relationship is the essential factor. In this article, we will apply the psychological constructs of transference and countertransference to the unique arena of palliative care communication. Although most palliative care clinicians are not mental health clinicians and have not received training or certification in psychotherapeutic techniques, there are elements from these frameworks that may be advantageously applied. We will draw on sources from psychology and psychiatry to explore the in-between spaces of clinical encounter. Using the case of Gloria, a patient living with cancer drawn from our clinical experience, we will offer adapted definitions and novel applications of these psychological concepts. Branching from the theory to everyday practice, we will then offer practical suggestions to guide the palliative care clinician in recognizing and managing strong countertransference reactions. This article is the third installment of a series on the psychological elements of palliative care.

This is the second article in the psychological elements of palliative care (PEPC) series. This series focuses on how key concepts from psychotherapy can be used in the context of palliative care to improve communication and fine tune palliative care interventions. In this article, we introduce two foundational concepts: frame and formulation. The frame is the context in which care is delivered; it includes concrete aspects of clinical care such as where it takes place, for how long, and with what frequency. It also includes the conceptual aspects of care, including the specific roles of the clinician and the patient, emergency contingencies, and the extent to which emotion is invited within the clinical encounter. Defining and discussing the frame with patients are especially important in palliative care because of the strong emotions that arise when talking about serious illness and because many patients may not be familiar with palliative care before they are in care. Formulation is the process by which we make judgment-neutral psychological hypotheses to understand the feelings and behaviors of our patients. It is an ongoing, dynamic process whereby as we learn more about our patients, we integrate that data to improve our explanatory model of who they are. This helps us tailor our interventions to meet their unique needs and respect their life experiences, aptitudes, and vulnerabilities. Both concepts are foundational PEPC; understanding them will prepare readers to continue to the next four articles in the series.

ObjectiveAlthough important treatment decisions are made in the Emergency Department (ED), conversations about patients’ goals and values and priorities often do not occur. There is a critical need to improve the frequency of these conversations, so that ED providers can align treatment plans with these goals, values, and priorities. The Serious Illness Conversation Guide has been used in other care settings and has been demonstrated to improve the frequency, quality, and timing of conversations, but it has not been used in the ED setting. Additionally, ED social workers, although integrated into hospital and home-based palliative care, have not been engaged in programs to advance serious illness conversations in the ED. We set out to adapt the Serious Illness Conversation Guide for use in the ED by social workers.MethodsWe undertook a four-phase process for the adaptation of the Serious Illness Conversation Guide for use in the ED by social workers. This included simulated testing exercises, pilot testing, and deployment with patients in the ED.ResultsDuring each phase of the Guide's adaptation, changes were made to reflect both the environment of care (ED) and the clinicians (social workers) that would be using the Guide. A final guide is presented.Significance of resultsThis report presents an adapted Serious Illness Conversation Guide for use in the ED by social workers. This Guide may provide a tool that can be used to increase the frequency and quality of serious illness conversations in the ED.

Background: Given the national shortage of palliative care specialists relative to the need for their services, engaging nonspecialists is important to ensure patients with serious illness have an opportunity to share their goals and values with their providers. Hospital medicine clinicians are well positioned to conduct these conversations given they care for many medically complex patients. Yet, little is known about the patient experience of inpatient goals and values conversations led by hospitalist teams. Objective: To assess patients' experience and perception of the quality of goals and values conversations. Design/Setting/Participation: Single center, tertiary care, nonrandomized, two group cohort trial of patients hospitalized on general medical inpatient units staffed by hospital medicine clinicians previously trained to conduct serious illness conversations. Intervention: An automated screening tool was used to identify patients at increased risk for unmet palliative needs. The multidisciplinary team was informed of the screen's results on the intervention units but not on the control units. Intervention unit clinicians were asked to consider talking with patients about their goals and values. Results: One hundred thirty patients participated in the study. The intervention patients 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. Conclusion: This study suggests that informing the care team regarding their patients' potential unmet palliative care needs is associated with patients reporting improved experience of their care without adverse effects on their mood.

Advanced cancer, with its considerable physical symptoms and psychosocial burdens, represents an existential threat and major stressor to patients and their caregivers. In response to such stress, patients and their caregivers use a variety of strategies to manage the disease and related symptoms, such as problem-focused, emotion-focused, meaning-focused, and spiritual/religious coping. The use of such coping strategies is associated with multiple outcomes, including quality of life, symptoms of depression and anxiety, illness understanding, and end-of-life care. Accumulating data demonstrate that early palliative care, integrated with oncology care, not only improves these key outcomes but also enhances coping in patients with advanced cancer. In addition, trials of home-based palliative care interventions have shown promise for improving the ways that patients and family caregivers cope together and manage problems as a dyad. In this article, we describe the nature and correlates of coping in this population, highlight the role of palliative care to promote effective coping strategies in patients and caregivers, and review evidence supporting the beneficial effects of palliative care on patient coping as well as the mechanisms by which improved coping is associated with better outcomes. We conclude with a discussion of the limitations of the state of science, future directions, and best practices on the basis of available evidence.

Palliative care has been shown to help patients live well with serious illness, but the specific psychological factors that contribute to this benefit remain investigational. Although support of patient coping has emerged as a likely factor, it is unclear how palliative care helps patients to cope with serious illness. The therapeutic relationship has been proposed as a key element in beneficial patient outcomes, possibly undergirding effective patient and family coping. Understanding the distress of our patients with psychological depth requires the input of varied clinicians and thinkers. The complex conceptual model we developed draws upon the contributions of medicine, nursing, psychology, spiritual care, and social work disciplines. To elucidate these issues, we convened an interdisciplinary seminar of content experts to explore the psychological components of palliative care practice. "Healing Beyond the Cure: Exploring the Psychodynamic Aspects of Palliative Care" was held in May 2019 at Harvard University's Radcliffe Institute for Advanced Study. Over two days, the working group explored these essential elements of successful palliative care encounters through lecture and open discussion. This special report describes the key psychological aspects of palliative care that we believe underlie optimal adaptive coping in palliative care patients. We also outline key areas for further development in palliative care research, education, and clinical practice. The discussion held at this meeting became the basis for a planned series of articles on the psychological elements of palliative care that will be published in the Journal of Palliative Medicine on a monthly basis during the fall and winter of 2021-2022.

Introduction Early conversations about patients’ goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. Methods We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. Results Eighty-six percent of students and 91% of residents rated the session as “very good” or “excellent” and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. Discussion Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.

CONTEXT. Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The “surprise question” (SQ) “Would you be surprised if this patient died in the next 12 months?” is a simple tool to identify patients at risk for 12-month mortality. OBJECTIVES. The objective of this study was to assess the accuracy of the SQ when used by EPs to assess patients with HF. METHODS. We conducted a prospective cohort study in which clinicians applied the SQ to patients presenting to the ED with symptoms of HF. Chart review and review of death records were completed. The primary outcome was accuracy of the surprise question to predict 12-month mortality. A univariate analysis for potential predictors of 12-month mortality was performed. RESULTS. During the study period, 199 patients were identified, and complete data were available for 97% of observations (n = 193). The one-year mortality was 29%. EPs reported that “they would not be surprised” if the patient died within the next 12 months in 53% of cases. 42.7% of these patients died within 12 months compared to 13.3% in the “would be surprised” group. There was a strong association with death in the “not surprised” group (odds ratio 4.85, 95% CI 2.34–9.98, P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of the SQ were 78.6%, 56.9%, 42.7%, and 86.7%, respectively, with c-statistic = 0.68. CONCLUSION. The SQ screening tool can assist ED providers in identifying HF patients that would benefit from early palliative care involvement.

With the palliative care workforce shortage and changes in advance care planning reimbursement, many institutions are requesting that palliative care specialists provide serious illness communication training across their institution's workforce. Based on our experience training clinicians to use the Partners Serious Illness Conversation Guide, a structured guide to teach basic palliative care communication skills, we propose a set of best practices to help others teach use of a communication guide at their institution, including fostering a safe learning environment, explicit teaching of structured communication, and preparing cofacilitators to adapt to differing skill levels of learners.

Background: Understanding patients' goals and values is important to ensure goal-concordant care; however, such discussions can be challenging. Little is known about the impact of having these discussions on hospitalists. Objective: To assess the impact on hospitalists of a system that reminds them to have serious illness conversations with their patients identified with potential unmet palliative needs. Design: Two group cohort trial. Setting/Subjects: Single academic center. Internal medicine hospitalist physicians, nurse practitioners, and physician's assistants. Measurements: Before the trial, all participants received serious illness conversation training. During the trial, 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. At baseline and three months, hospitalists completed questionnaires regarding communication skill acquisition, perception of the importance of these conversations, and sense of the meaning gained from having them. Results: Both groups had similar improvements in their self-reported communication skills and experienced a small decline in how important they felt the conversations were. Neither group perceived having the discussions as being affectively harmful to patients. The intervention hospitalists, over time, reported a slight reduction in the sense of meaning they achieved from the conversations. Conclusion: 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. It is likely the pretrial training accounted for many of the positive outcomes in communication skills observed in both arms of the trial.

A Man with Acute Respiratory Failure and Unclear Goals of Care A 74-year-old man with lymphoma was admitted to the hospital during the Covid-19 pandemic because of rapidly progressive respiratory f...

Background: Growing evidence demonstrates the benefits of early, integrated palliative care (PC) for patients with advanced cancer and their caregivers. Yet, data are lacking on the communication patterns within this model of care. Objective: The goals of this study were to describe the content of patient–clinician discussions among patients receiving PC and to compare differences in discussion content between oncologists and PC clinicians. Design: We conducted a qualitative observational analysis. Setting/Subjects: We included patients with incurable lung and esophageal cancer enrolled in a randomized trial of early, integrated PC versus usual oncology care. We analyzed 68 audio-recorded clinic visits (34 oncologist visits; 34 PC clinician visits) immediately after patients' (N = 19) first and second cancer progressions. We examined themes of clinician communication, comparing the content and frequency of discussions between oncologists and PC clinicians. Results: Although both oncology and PC clinicians discussed symptom management, medical understanding, and treatment decision making with patients at nearly all postprogression visits, PC clinicians tended to assess patient understanding of the treatment process and prognosis more often than oncologists. PC clinicians addressed patient coping, caregiver experiences and needs, and advance care planning more frequently than oncologists. Conclusion: PC clinicians play a distinct, complementary role to oncologists in providing care for patients with advanced cancer and their caregivers. PC clinicians tend to assess and elaborate on patient understanding of prognosis and treatment and emphasize effective coping, caregiver needs, and advance care planning. These results illuminate the communication elements by which early, integrated PC may improve patient and caregiver outcomes.

Purpose The early integration of oncology and palliative care (EIPC) improves quality of life (QOL) and mood for patients with advanced cancer. However, the mechanisms by which EIPC benefits these outcomes remain unclear. We therefore examined whether EIPC improved patients’ coping strategies and if changes in coping accounted for intervention effects on QOL and depressive symptoms. Patients and Methods For this secondary analysis of an EIPC trial, we examined data from 350 patients with newly diagnosed incurable lung or GI cancer. Participants completed assessments of QOL (Functional Assessment of Cancer Therapy–General), depressive symptoms (Patient Health Questionnaire–9), and coping (Brief COPE) at baseline and 24 weeks. We used linear regression to test intervention effects on use of coping strategies and mediation regression models with bias-corrected bootstrapping to examine whether improvements in coping mediated the effects of early palliative care on patient-reported outcomes. Results Compared with usual oncology care, EIPC significantly increased patient use of approach-oriented coping strategies ( B = 1.09; SE = 0.44; P = .01) and slightly reduced use of avoidant strategies ( B = −0.44; SE = 0.23; P = .06) from baseline to 24 weeks. Also, the increased use of approach-oriented coping and reduction in avoidant coping were associated with higher QOL and lower depressive symptoms at 24 weeks. The positive changes in approach-oriented coping, but not avoidant coping, significantly mediated the effects of EIPC on QOL (indirect effect, 1.27; 95% CI, 0.33 to 2.86) and depressive symptoms (indirect effect, −0.39; 95% CI, −0.87 to −0.08). Conclusion Patients with incurable cancer who received EIPC showed increased use of approach-oriented coping, which was associated with higher QOL and reduced depressive symptoms. Palliative care may improve these outcomes by providing patients with the skills to cope effectively with life-threatening illness.

Background The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown. Materials and methods We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short-Form to assess caregiver mood and QOL. Results Two hundred seventy-five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers' total distress (HADS-total adjusted mean difference = -1.45, 95% confidence interval [CI] -2.76 to -0.15, p = .029), depression subscale (HADS-depression adjusted mean difference = -0.71, 95% CI -1.38 to -0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers' outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers' total distress (HADS-total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death. Conclusion Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. Implications for practice Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers' psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.

Background We aim to address palliative care workforce shortages by teaching clinicians how to provide primary palliative care through peer coaching. Intervention We offered peer coaching to internal medicine residents and hospitalists (attendings, nurse practioners, and physician assistants). Measures An audit of peer coaching encounters and coachee feedback to better understand the applicability of peer coaching in the inpatient setting to teach primary palliative care. Outcomes Residents and hospitalist attendings participated in peer coaching for a broad range of palliative care–related questions about pain and symptom management (44%), communication (34%), and hospice (22%). Clinicians billed for 68% of encounters using a time-based billing model. Content analysis of coachee feedback identified that the most useful elements of coaching are easy access to expertise, tailored teaching, and being in partnership. Conclusion/Lessons Learned Peer coaching can be provided in the inpatient setting to teach primary palliative care and potentially extend the palliative care work force.

Background We designed group coaching calls to reinforce communication skill acquisition and Serious Illness Care Program (SICP) uptake in adult primary care. Measures Percentage of primary care physicians who have documented a Serious Illness Conversation in the electronic health record (EHR) approximately 3 and 6 months after the coaching intervention. Participant feedback surveys to better understand provider attitudes toward the coaching intervention. Intervention. We offered 60-minute group coaching calls to internal medicine primary care physicians, previously trained in serious illness conversation skills, as part of an institutional quality incentive program. The calls addressed communication challenges common to serious illness care and instructed participants about how to document and bill for conversations. Outcomes. We completed 31 coaching calls over three months in which 170 of 228 primary care physicians attended in groups of 2-9 participants per call (74.6% penetration rate). The percentage of primary care physicians who documented at least one Serious Illness Conversation in the electronic health record increased from 18.4% to 41.2% six months after the intervention. Primary care internal medicine physicians found the one-hour coaching calls to be highly valuable, with 86.9% of respondents attesting they would recommend the calls to their colleagues. Content analysis of participant feedback identified the most useful coaching content elements to be self-reflection around the impact of prior conversation skills training, instruction around using the EHR to find and document ACP discussions, the opportunity to share individual challenges and successes with peers, and feedback/advice from communication experts in palliative care. Conclusions/Lessons Learned Group coaching of primary care physicians resulted in more than a two-fold increase in documented serious illness conversations.

BackgroundThe communication process of preparing patients and families facing progressive neurodegenerative diseases for future illness has not been empirically elucidated; the goal of this qualitative study was to explore neurology interdisciplinary health professionals' communication experiences, including current approaches, facilitators, and challenges.MethodsThree focus groups were conducted with 22 clinicians representing a range of health professions from several multidisciplinary neurology outpatient clinics at a large academic medical center. A thematic analysis approach was used to develop a coding structure and identify overarching themes.ResultsNeurology clinicians highlighted that in their practice, (1) conversations are triggered by acute events and practical needs; (2) conversations occur routinely but are rarely documented; (3) loss of patient capacity and resultant surrogate decision-making can be ethically fraught, especially in times of family conflict; (4) prognostic uncertainty, unfamiliarity with disease trajectories, and patient or surrogate avoidance pose communication challenges; and (5) generalist- and specialty-level palliative care roles should be better defined.ConclusionsThere is a need for a systematic, structured approach to communication that can be applied early in the disease trajectory and considered when developing integrated neuro-palliative care programs.

1008 Background: Studies have demonstrated the benefits of early, integrated palliative care in improving quality of life (QOL) and end-of-life (EOL) care for patients with poor prognosis cancers. However, the optimal timing and outcomes of delivering palliative care for those with advanced cancers that have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a collaborative palliative and oncology care model on communication about EOL care in patients with MBC. Methods: Patients with MBC and clinical indicators of poor prognosis (N=120) were randomized to receive collaborative palliative and oncology care or usual care between 05/02/2016 and 12/26/2018. The intervention entailed five structured palliative care visits, including a joint visit with oncology when possible, which focused on symptom management, coping, prognostic awareness, decision-making, and planning for EOL. The primary outcome was documentation of EOL care discussions in the electronic health record. Patients also completed questionnaires at baseline and 6, 12, 18, and 24 weeks regarding communication with clinicians about EOL care, QOL, and mood symptoms. Results: The sample included only women (100.0%) who mostly identified as white (87.5%), with a mean age of 56.91 years (SD=11.24). The rate of EOL care discussions documented in the health record was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%, p=0.006), including a higher completion rate of a Medical Orders for Life Sustaining Treatment form (39.3% vs 13.6%, p=0.002). Intervention patients were also more likely to report discussing their EOL care wishes with their doctor compared to usual care patients (OR=3.10, 95% CI: 1.21, 7.94, p=0.019). Study groups did not differ in reported QOL or mood symptoms. Conclusions: This novel collaborative palliative care intervention significantly improved communication and documentation regarding EOL care for women with MBC. Further work is needed to examine the effect of this care model on healthcare utilization at the end of life.

Purpose We describe the key elements of early palliative care (PC) across the illness trajectory and examine whether visit content was associated with patient-reported outcomes and end-of-life care. Methods We performed a secondary analysis of patients with newly diagnosed advanced lung or noncolorectal GI cancer (N = 171) who were randomly assigned to receive early PC. Participants attended at least monthly visits with board-certified PC physicians and advanced practice nurses at Massachusetts General Hospital. PC clinicians completed surveys documenting visit content after each encounter. Patients reported quality of life (Functional Assessment of Cancer Therapy–General) and mood (Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9) at baseline and 24 weeks. End-of-life care data were abstracted from the electronic health record. We summarized visit content over time and used linear and logistic regression to identify whether the proportion of visits addressing a content area was associated with patient-reported outcomes and end-of-life care. Results We analyzed data from 2,921 PC visits, most of which addressed coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher proportion of visits that addressed coping experienced improved quality of life ( P = .02) and depression symptoms (Depression subscale of the Hospital Anxiety and Depression Scale, P = .002; Patient Health Questionnaire-9, P = .004). Patients who had a higher proportion of visits address treatment decisions were less likely to initiate chemotherapy ( P = .02) or be hospitalized ( P = .005) in the 60 days before death. Patients who had a higher proportion of visits addressing advance care planning were more likely to use hospice ( P = .03). Conclusion PC clinicians’ focus on coping, treatment decisions, and advance care planning is associated with improved patient outcomes. These data define the key elements of early PC to enable dissemination of the integrated care model.

We present a case illustrating the common problem of a surrogate decision maker who is psychologically distressed over the medical team's recommendation to withdraw life-sustaining treatment. We suggest how a do-not-escalate-treatment (DNET) order can be helpful in such situations when the usual approaches to withholding or withdrawing care are not acceptable to the surrogate. We define a DNET order, explain when it might be useful, and discuss how it can facilitate a humane, negotiated resolution of differences.

Background: Early palliative care provides better quality of life, increased prognostic awareness, and even improved survival for patients with advanced cancer but how the integrated care model achieves these outcomes has not been completely explained. Methods: To better understand the clinical approach to early outpatient care from the clinicians' perspective, we conducted focus groups with the palliative care clinicians who had participated in a randomized trial of early palliative care for metastatic lung cancer. Results: Clinicians described their role in providing early palliative care as having three distinct roles in the outpatient setting: (1) managing symptoms to improve functional status and as a bridge to other issues; (2) engaging patients in emotional work to facilitate coping, accepting, and planning; and (3) interpreting the oncologist for the patient and the patient for the oncologist. Conclusions: These data lay the foundation for developing training programs for clinicians in ea...

Continuity outpatient palliative care practice is characterized by long relationships between patients, families, and palliative care clinicians and by periods of relative stability when the disease and resultant symptoms are less active. Compared to inpatient palliative care, outpatient practice requires a greater focus on encouraging healthy coping and on helping patients to live well with serious illness. This paper discusses the opportunities to promote adaptive coping in the delivery of outpatient palliative care.

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v −3.40; P = .010) but not week 12 (0.39 v −1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, −1.17; 95% CI, −2.33 to −0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Patients with advanced cancers represent a particularly vulnerable population given their medical complexity, high symptom burden, often incurable prognosis, and need to make critical decisions about care at the end of life. Over the last decade, a new model of outpatient palliative care has shown great promise and efficacy in meeting these many challenges for patients and their families. Palliative care typically consists of a multidisciplinary team of physicians, nurses, social workers, and chaplains who provide services to enhance symptom management, psychosocial and spiritual support, and assistance with treatment decision-making for patients and families coping with serious illness. A number of clinical trials have demonstrated that outpatient palliative care, delivered simultaneously or integrated with oncology care from the time of diagnosis of advanced cancer, leads to improved quality of life, lower rates of depression, more accurate prognostic understanding, as well as less aggressive and higher quality care at the end of life. In this chapter, we (1) provide the rationale for delivering palliative care services early in the course of disease for patients diagnosed with advanced cancer, (2) review the evidence base for this new model of integrated palliative care, (3) highlight the key clinical interventions, and (4) describe a case example using the approach.

Background Patients with metastatic non–small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. Methods We randomly assigned patients with newly diagnosed metastatic non–small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. Results Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P = 0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P = 0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P = 0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = 0.02). Conclusions Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

92 Background: In a recent trial, early integrated palliative care (PC) improved quality of life (QOL) and reduced depressive symptoms in patients with newly-diagnosed incurable lung and gastrointestinal (GI) cancer. The mechanisms by which PC benefits these outcomes are unclear. We examined whether early integrated PC improved patients’ coping strategies and the degree to which changes in coping mediated intervention effects on QOL and depressive symptoms. Methods: From 5/2011 to 7/2015, we enrolled 350 patients with newly diagnosed incurable lung or non-colorectal GI cancer in a randomized trial of early PC integrated with oncology care vs. oncology care alone at Massachusetts General Hospital. Patients completed self-report measures of QOL (Functional Assessment of Cancer Therapy-General), depressive symptoms (Patient Health Questionnaire-9), and use of active and avoidant coping strategies (Brief Cope) at baseline, 12, and 24 weeks. Linear regression was used to assess the effects of the early PC intervention on active and avoidant coping strategies. A multiple mediation regression was modeled to examine whether changes in use of coping strategies mediated intervention effects on QOL and depressive symptoms. Results: Compared to oncology care, early integrated PC improved patients’ use of active coping ( B= 1.09, SE= 0.44, p= .01, 95% CI: 0.23, 1.96) and slightly reduced use of avoidant coping strategies ( B= -0.44, SE= 0.23, p= .06, 95% CI:-0.90, 0.02). Improvements in 24-week QOL in patients assigned to PC were mediated by increased use of active coping strategies (indirect effect = 1.27, 95% CI: 0.31, 2.86), but not by decreased use of avoidant coping. Similarly, PC-related reductions in 24-week depressive symptoms were mediated by increased use of active coping strategies (indirect effect = -0.39, 95% CI:-0.89, -0.08) but not by decreased use of avoidant coping. Conclusions: Patients with newly diagnosed incurable cancer who received early integrated PC showed increased use of active coping strategies, which was associated with improved QOL and depressive symptoms. PC may improve QOL and mood by providing patients with the skills to cope effectively with life-threatening illness. Clinical trial information: NCT01401907.

10023 Background: In a recent trial, early integrated palliative care (PC) improved quality of life (QOL) and reduced depression symptoms in patients with newly-diagnosed incurable lung and gastrointestinal (GI) cancer. The mechanisms by which PC benefits these outcomes are unclear. Therefore, we examined whether early integrated PC improved patients’ coping strategies and the degree to which changes in coping mediated intervention effects on patient-reported QOL and depression symptoms. Methods: From 5/2011 to 7/2015, we enrolled 350 patients with newly diagnosed incurable lung or non-colorectal GI cancer in a randomized trial of early PC integrated with oncology care vs. oncology care alone at Massachusetts General Hospital. Patients completed self-report measures of QOL (Functional Assessment of Cancer Therapy-General), depression symptoms (Patient Health Questionnaire-9), and use of active and avoidant coping strategies (Brief Cope) at baseline, 12, and 24 weeks. Linear regression was used to assess the effects of the early PC intervention on active and avoidant coping strategies. A multiple mediation regression with bias-corrected bootstrapping was modeled to examine whether changes in use of coping strategies mediated intervention effects on QOL and depression symptoms. Results: Compared to oncology care, early integrated PC improved patients’ use of active coping and reduced use of avoidant coping strategies. Improvements in 24-week QOL in patients assigned to PC were mediated by increased use of active coping strategies (indirect effect = 1.27, bootstrapped SE = 0.65, 95% CI [0.31, 2.86]), but not by decreased use of avoidant coping. Similarly, PC-related reductions in 24-week depression symptoms were mediated by increased use of active coping strategies (indirect effect = -0.39, bootstrapped SE = 0.20, 95% CI [-0.89, -0.08] but not by decreased use of avoidant coping. Conclusions: Patients with newly diagnosed incurable cancer who received early integrated PC showed increased use of active coping strategies, which led to improved QOL and depression symptoms. PC may improve QOL and mood by providing patients with the skills to cope effectively with life-threatening illness. Clinical trial information: NCT01401907.

Early, integrated palliative care delivered in the ambulatory setting has been associated with improved quality of life, lower rates of depression, and even prolonged survival. We outline an expert practice that provides a step-wise approach to cultivating prognostic awareness in patients cared for by a palliative care clinician early in the course of the patient's disease. This approach can be used by both novice and more experienced palliative care clinicians.

234 Background: Patients with newly diagnosed advanced cancers who receive early palliative care (PC) integrated with oncology care report improvement in their quality of life (QOL) and mood. While a telephone-based psycho-educational intervention for FC decrease depression, the impact of early, integrated outpatient PC models on FC outcomes remains unknown. Methods: We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for newly diagnosed patients with incurable lung and gastrointestinal cancers and their FC. Eligible FC were relatives or friends who would likely accompany the patient to clinic visits. FC were eligible to enroll up to 4 weeks after patient enrollment. The intervention entailed at least monthly patient visits with PC from the time of enrollment. FC were not required to attend these visits. We used the Medical Outcomes Study Health Survey Short Form-36 to examine QOL and the Hospital Anxiety and Depression Scale to examine mood at baseline, weeks 12 and 24. We used the two-sample t-test to examine changes in QOL and mood from baseline to week 12 and week 24. Results: We enrolled 350 patients and 275 (78.6%) of potentially eligible FC (control n = 138, intervention n = 137) between 5/2/2011 to 7/20/2015. FC outcomes missing data rate at 12 and 24 weeks were 16.8% and 33.8% respectively. At 12 weeks, FC of patients receiving early PC reported higher vitality (1.1 vs. -3.2, p = 0.05) and social functioning (-3.0 vs. -3.8, p = 0.02), and lower depression symptoms (-0.45 vs. 0.24, p = 0.03) compared to FC of patients assigned to usual care. At 24 weeks, FC of patients assigned to early PC had lower depression symptoms (-0.37 vs. 0.28, p = 0.05), but no differences in vitality or social functioning compared to those receiving usual care. No differences in other SF-36 subscales or anxiety were noted at 12 and 24 weeks. Conclusions: Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvements in FC depression and aspects of QOL. This work demonstrates that the benefits of early, integrated palliative care models in oncology care extend beyond patient outcomes and positively impact the experience of FC. Clinical trial information: NCT01401907.

10003Background: Early palliative care (PC) improves outcomes in patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC) and in patients identified by clinicians as having poor prognosis, advanced cancer. We evaluated the impact of early, integrated palliative and oncology care in patients with newly diagnosed lung and gastrointestinal (GI) cancer. Methods: We randomly assigned patients with newly diagnosed incurable lung (NSCLC, small cell, mesothelioma) or GI (pancreas, hepatobiliary, gastric, esophageal) cancer to PC integrated with oncology care (at least monthly visits with PC) or usual oncology care. We used the Functional Assessment of Cancer Therapy-General (FACT-G) to assess quality of life (QOL) and the Patient Health Questionniare-9 (PHQ-9) and Hospital Anxiety and Depression Scale (HADS) for mood at baseline, weeks 12 and 24. We assessed patients’ perception of their likelihood of cure and their communication about their end of life (EOL) preferences. WΒe used linear regres...

10131Background: Patients with newly diagnosed advanced cancers who receive early palliative care (PC) integrated with oncology care report improvement in their quality of life (QOL) and mood. Whil...

Called in after discussions about prognosis between referring clinicians and patients, palliative care consultants sometimes find that the patient does not seem to understand what the referring clinician believes he or she explained. However, holding a more explicit discussion about prognosis may compromise the palliative care clinician's rapport with both the patient and the referring clinician. We therefore propose a two-part approach to explore apparent prognostic misunderstandings: first, generate a differential diagnosis for why the patient and referring clinician have different reports of what was said, and second, cultivate a partnership with the referring clinician to provide a unified patient care plan.

Although palliative care consultation is recommended early in the course of oncology treatment, little evidence exists to guide the nature of this intervention. We describe a clinical practice of early palliative care consultation that improved quality of life, mood, and survival in a randomized clinical trial.As part of a randomized trial of early palliative care versus standard care in patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC), we analyzed documentation of the components of the initial palliative care consultation, self-reported quality of life as measured by the Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (FACT-L TOI), and mood as measured by the Patient Health Questionnaire-9 (PHQ-9).Seven palliative care clinicians provided consultation to 67 patients. The median total time spent with patients for the initial visit was 55 minutes (range, 20-120). Consultations focused on symptom management (median, 20 minutes; range, 0-75), patient and family coping (median, 15 minutes; range, 0-78), and illness understanding and education (median, 10 minutes; range, 0-35). Lower quality of life as measured by the FACT-L TOI predicted greater consultation time (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91-0.99). Additionally, lower quality of life scores on the FACT-L TOI (OR = 0.93, 95% CI = 0.88-0.97) and higher depression scores on the PHQ-9 (OR = 1.15, 95% CI = 1.02-1.31) predicted greater time spent on symptom management.Initial palliative care consultation near the time of diagnosis in patients with metastatic NSCLC in this intervention is nearly an hour in length and largely addresses symptom management, patient and family coping, and illness understanding and education. Lower quality of life predicted longer consultations, with more time dedicated specifically to symptom management.

Subcutaneous lymphatic drainage has been reported to be an effective treatment for severe refractory lymphedema in patients with lymphatic accumulation because of obstructive cancer. We review published techniques for lymphatic drainage and describe two cases where these techniques were modified with good results.

Objectives Discuss the role of the outpatient palliative care clinician as supportive psychotherapist. Identify and practice clinical skills from the positive psychology literature to help patients build resilience and adaptive coping in the face of serious illnesses. Discuss techniques to enable patients to tolerate greater discussion of prognosis and the possibility of death. Continuity outpatient palliative care practice offers an opportunity for palliative care clinicians to support patients longitudinally through the process of medical decision-making. This session will discuss how clinicians can support patients in both living well and engaging in values-based medical decision-making using techniques from supportive psychotherapy within a medical framework. We will explore how palliative care clinicians can partner with the patient to engage in a fully emotional, encouraging, and supportive relationship. Participants will learn and practice techniques to reinforce patients’ healthy and adaptive patterns of thought and behavior in order to build resilience in the face of illness and maintain quality of life. We will also discuss how to help patients develop a deeper awareness of and ability to tolerate discussions of clinical decline and the possibility of death. By building prognostic awareness and resilience, clinicians enable patients to be more fully informed and cope more effectively when making decisions about medical treatment.

Objectives 1. Define pop culture/visual arts and describe their importance in educational techniques and applicability in palliative and end-of-life teaching. 2. Describe and demonstrate the use of popular visual arts to directly link effective visual learning and palliative care education. 3. Discuss how to develop attendees’ skills to incorporate this method into a standard educational framework and provide specific resources to attendees. The goal of this session is to repackage available media into a palliative care context, thereby transforming its purpose from entertainment to education. Palliative care education is paramount in transforming our healthcare system from a fragmented care model to a patient and family-centered model. The recipients of this education must be able to understand its importance in the care of seriously ill patients. A key component in education is the understanding of how people learn. The main learning styles can be classified into auditory, visual, and kinesthetic (body motion). Since 60% of the population consists of visual learners, visual methods of instruction are crucial to teaching. This is particularly important in teaching a subject that involves a paradigm shift from previously learned perceptions and ideas. The best visual learning in medicine takes place at the bedside with a skilled clinician. However, the classroom environment is still an important forum for relaying new information. Current methods of palliative care instruction include oral lecture, role play, and use of computerized visuals (power point, etc.). Oral lecture and role play are particularly effective for verbal and kinesthetic learners. Commonly used computerized visuals, however, generally do not evoke strong emotional responses which can be useful in integrating an important concept into memory. The missing component of learning is often an emotional one. Emotion drives attention and attention drives learning. The use of popular media and visual arts offers a teaching method that stimulates the visual learner by provoking emotion and focusing attention on the important aspects of palliative care. This session seeks to share specific popular media examples paired with palliative care concepts that will assist visual learners with integrating palliative care concepts.

importance of spiritual care in palliative care. Recommendations for implementing these guidelines in palliative care, including a model for assessing and integrating spirituality into patients’ treatment plans, were developed at a national consensus conference, ‘‘Improving the Quality of Spiritual Care in Palliative Care,’’ led by the City of Hope and The George Washington Institute for Spirituality and Health (GWish). This work was published in JPM in 2009 and in a book, Making Healthcare Whole, in 2010. We have presented this material in two precourses at the AAHPM annual meetings in 2010 and 2011. In 2012 and 2013, we presented well-received advanced spiritual care precourses based on participant feedback. We have been strongly encouraged to propose this again with the addition of more case based discussions in the introduction and a section on how to take what was learned back to the participants’ settings. This workshop describes how to identify spiritual issues, do a spiritual history, and develop an interdisciplinary treatment plan that includes patients in the development of their treatment plan. Standardized patients from UCSD School of Medicine will be used for this session. There will be an online password protected learning community on the GWish website for participants to review basic background material prior to coming to the advanced course. This will include the FICA spiritual assessment DVD training. The standardized patients and the online community will be paid for by GWish. Participants will learn how to address patients’ spirituality in a systematic way, how to identify spiritual issues, and how to develop a treatment plan with an interdisciplinary team. They will develop plans to integrate what they learn into their clinical settings.

Outpatient Palliative Care: Why It Is Important, How to Build It at Your Institution, and How to Deliver the Care (P9) (Advanced) Vicki Jackson, MD MPH, Massachusetts General Hospital, Boston, MA. Juliet Jacobsen, MD, Massachusetts General Hospital, Boston, MA. Connie Dahlin, ACHPN ANP, Massachusetts General Hospital Palliative Care Service, Boston, MA. Margaret Seaver, MD MPH, Lahey Clinic Medical Center, Burlington, MA. Sponsored by AAHPM (All speakers for this session have disclosed no relevant financial relationships.)

7509 Background: Patients withmetastatic NSCLC face significant physical and psychological symptoms and receive aggressive care at the EOL. The goal of this study was to examine the impact of early...

e20635 Background: Many experts recommend palliative care consultation early in the course of oncology treatment; however little is known about the components of this type of intervention. We sought to better define the components of early palliative care consultation in patients with recently diagnosed incurable cancer. Methods: As part of a larger randomized study of integrated versus standard palliative care in an ambulatory thoracic oncology clinic, we analyzed data from 47 patients who received early palliative care consultation within eight weeks of diagnosis of incurable NSCLC with a performance status of 0–2. Prior to randomization, patients completed questionnaires on quality of life (FACT-L) and mood (HADS) as well as illness understanding. The FACT-L Trial Outcome Index which is a combined score of physical, functional well being, and lung cancer symptoms was calculated and used in correlations to more fully assess quality of life. After the consultation, palliative care clinicians recorded how time was spent during the encounter. Results: Seven palliative care clinicians provided consultation to 47 patients. The mean total time spent with each patient was 59.5 minutes (SD 28.6). The major components of each consultation were symptom management 25.7 minutes (SD 15.8), patient and family coping 19.6 minutes (SD 14.7), and illness understanding and education 10.4 minutes (SD 7.6). Greater total consultation time was correlated with poorer performance status (r=0.30, p=0.04) and lower quality of life scores on the FACT-L TOI which is a combined score of physical, functional wellbeing, and lung cancer symptoms (r=0.36, p=0.01). Symptom management time was also correlated with lower quality of life scores on the FACT-L TOI (r-0.52, p No significant financial relationships to disclose.

9515 Background: Accurate understanding of prognosis among terminally-ill patients impacts decision-making at the end of life. The goal of this study was to explore illness understanding in patients with advanced non-small cell lung cancer (NSCLC). Methods: As part of a larger randomized study of integrated versus standard palliative care in an ambulatory thoracic oncology clinic, we recruited 120 patients within eight weeks of diagnosis of incurable NSCLC with a performance status of 0–2. Prior to randomization, patients completed questionnaires on quality of life (FACT-L) and mood (HADS), as well as the following items regarding illness understanding: 1) “My cancer is curable” (yes/no); “The goals of my therapy are: to help me live longer” (yes/no), “try to make me feel better” (yes/no), “to get rid of all my cancer” (yes/no); and 3) “My current health status is: relatively healthy, seriously but not terminally ill, or seriously and terminally ill”). Results: Approximately one third of patients (n=39/116, 33.6%) believed their cancer to be curable. While most patients felt that the goals of therapy were to help them live longer (n=110/113, 97.3%) and feel better (n=102/102, 100%), 66.0% (n=64/97) also believed that getting rid of all of the cancer was a treatment goal. Only 13.9% (n=16/115) of patients believed that their current health status was seriously and terminally ill. Patients who reported greater depression and anxiety symptoms on the HADS were more likely than those without such distress to believe that their cancer was curable (OR=2.47, p=.03) and that one of the goals of treatment was to get rid of all of their cancer (OR=3.83, p=.02). Conclusions: Despite having an incurable illness, the majority of patients with advanced NSCLC do not view themselves as terminally ill or have an accurate understanding of the goals of anti-cancer therapy. Given that patients often make treatment decisions based on their prognostic awareness, many of these individuals, particularly those with comorbid mood symptoms, may be at risk of pursuing unsuitable choices for their care. Interventions are needed to promote greater understanding of prognosis and goals of therapy in this population. No significant financial relationships to disclose.