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Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.

1. Through a review of exam outlines, participants will realize the lack of consistency in the end-of-life ethics content between residencies that lead into HPM fellowship. 2. Participants will recognize the relevance of standardizing ethics education across HPM fellowship programs. Ethics training is essential to hospice and palliative medicine (HPM) training. Ten residencies feed into HPM fellowship, but clinical ethics tested on board certification exams vary in content and weight across specialties. Given this variance, standardizing end of life ethics training for HPM fellowship programs presents an opportunity for educational improvement. The essence of end-of-life (EOL) communication stems from understanding modern bioethical principles and how they relate to topics such as informed consent, advance directives, DNR, surrogate decision-making, decision-making capacity, artificial nutrition and hydration, advance care planning/goal setting, and withdrawing life-sustaining treatments.1 Hospice and palliative medicine (HPM) training involves teaching fellows relevant ethics topics, acclimating them with discussing and handling ethical dilemmas with cultural humility and gaining the perspectives of involved stakeholders.2 There are ten residency programs (Anesthesiology, Emergency Medicine, Family Medicine, Internal Medicine, OBGYN, Pediatrics, PMR, Psychiatry and Neurology, Radiology, and Surgery) which can lead into HPM fellowship. However, EOL ethics tested on board certification exams vary in content and weight across specialties. This study reviewed EOL ethics content tested by board certification exams from residencies that lead into HPM fellowship across specialties. This study analyzed relative frequencies of EOL ethics categories across and within specialties from the respective board certification exam content outline. The relative frequencies of categories across specialties were 23.5% informed consent; 17.6% advance directives; 11.8% DNR; 11.8% surrogate decision-making; 11.8% decision-making capacity; 11.8% advance care planning/goal setting; and 11.8% withdrawing life-sustaining treatment. The relative frequencies of categories within specialties were 28.1% Surgery; 15.6% Emergency Medicine; 12.5% Anesthesiology; 12.5% Internal Medicine; 9.4% Psychiatry and Neurology; 6.3% Family Medicine; 6.3% Obstetrics and Gynecology; 6.3% Pediatrics; 3.1% PMR; and 0% Radiology. Our findings indicate that end-of-life ethics content tested on these board certification exams vary across specialties. Given this variance, standardizing end-of-life ethics training for HPM fellowship programs presents an opportunity for educational improvement. Ethical / Legal Aspects of Care [ABSTRACT FROM AUTHOR]

Rationale: Early identification of ICU patients likely to benefit from specialist palliative care could reduce the time such patients spend in the ICU receiving care inconsistent with their goals., Objective: To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU., Methods: We performed a retrospective cohort study in adults admitted to the ICU using a causal inference approach with instrumental variable analysis. The intervention consisted of screening ICU admissions for palliative care trigger conditions, and if present, offering specialist palliative care consultation which could be accepted/declined by the ICU. We evaluated specialist palliative care use in pre- and post-implementation cohorts from the year before/after screening implementation began (October 2022). In the post-implementation cohort, we compared use of specialist palliative care in those who received early screening versus not. We then estimated the effect of early screening on the primary outcome of days to do-not-resuscitate (DNR) code status or ICU discharge, with death without a DNR order placed at the 99 th percentile of the days to DNR or ICU discharge distribution. Secondary outcomes included: DNR order, ICU/hospital lengths of stay, hospice discharge, and mortality metrics. To address unmeasured confounding, we used two-stage least-squares instrumental variables analysis. The instrument, which predicts early screening, comprised weekend vs. weekday admission and number of patients meeting palliative care criteria on a patient's ICU days 1 and 2., Results: Amongst 1282 post-implementation admissions, 626 (45%) received early screening, and 398 (28%) received specialty palliative consultation. Early receipt of specialist palliative care was higher in patients who received early screening vs. not (17% vs 1% , p<0.001), and overall use of specialty palliative care was higher post- vs. pre-screening implementation (28 vs. 15%, p<0.001). In the post-implementation cohort, there were no statistically significant effects of early screening on the primary outcome of days to DNR or ICU discharge (15% relative increase, 95% CI [-11% to +48%]) or other secondary outcomes., Conclusions: Despite significantly increased specialty palliative care consultation there was no evidence that early screening for palliative care criteria affected time to DNR/ICU discharge or other secondary outcomes.

Competing Interests: None declared.