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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. more...

The Coronavirus disease 2019 (COVID-19) pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of severe acute respiratory syndrome-Coronavirus-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for nonpalliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop Web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, as well as on serious illness communication, including conversations about goals of care, code status, and end of life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to nonpalliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults and increasing acceptance of palliative care across hospital settings. more...

Thanks to the efforts of many individuals and organizations, the field of Hospice and Palliative Medicine (HPM) has undergone unprecedented growth over the last two decades. To meet the needs of seriously ill patients and families in inpatient, outpatient community setting in the future, the field of HPM must develop innovative strategies to expand the specialist workforce pipeline. With 148 programs participating in the National Residency Matching Program and 285 matched applicants in 2019, the specialty of HPM can barely replace those who are retiring or leaving the field. We call for a renewed and coordinated effort to increase the applicant pool for HPM fellowship positions, as well as greater access to specialist HPM training through expanded traditional fellowship programs and innovative specialist training pathways. Without such an expansion, our specialty will struggle to serve those patients and families who need us most. more...

Bereavement care is considered an integral component of quality end-of-life care endorsed by the palliative care movement. However, few hospitals and health care institutions offer universal bereavement care to all families of patients who die. The current coronavirus disease 2019 pandemic has highlighted this gap and created a sense of urgency, from a public health perspective, for institutions to provide support to bereaved family members. In this article, drawing on the palliative care and bereavement literature, we offer suggestions about how to incorporate palliative care tools and psychological strategies into bereavement care for families during this pandemic. more...

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision-making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision-makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual-, clinician-, and system-related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision-makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision-making capacity, identifying surrogate decision-makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care. more...

Despite increasing attention in the medical and nursing literature about the importance of self-care for clinicians and the prevention of burnout, coping with the deaths of patients is an often-neglected component of clinical training. In this article, we describe the development of "Remembrance," an interdisciplinary approach to acknowledge and process the deaths of patients on our inpatient palliative care service, paying particular attention to how patients and their families affect us as clinicians. We believe that such a practice is an important component of both quality end-of-life care and clinician self-care, which should be routinely taught and incorporated into clinical services. We provide a template that summarizes our approach, which can be easily adapted by other hospitals to use. more...

Breaching the Professional–Personal Boundary The boundary between physicians’ personal and professional lives is breached when we’re called on to care for people we know personally. Burnout may be ... more...

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision-making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision-makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual-, clinician-, and system-related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision-makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision-making capacity, identifying surrogate decision-makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care. more...

When a patient seems to have unrealistic hopes in the face of a grave prognosis, it is the clinician's responsibility to identify barriers to his or her understanding, assess reasons for continued hopefulness, evaluate the risks and benefits of more frank discussions, offer information about prognosis, and obtain a surrogate decision maker if time is short. more...

Giving feedback is a core element of medical education, one that is gaining attention but with a thin evidence base to guide medical educators. This review provides a definition of feedback and its purpose, selectively reviews the literature regarding educators' and learners' attitudes toward feedback, and provides an algorithm for giving feedback.The authors discuss the parallels between giving feedback and breaking bad news, emphasizing the importance of titrating the amount of information given, attending to affect, and making a plan for next steps. Special considerations for giving feedback in palliative care are highlighted, including the effect of heightened emotion in the clinical encounter and the difficulties of giving feedback about communication skills. more...

This chapter discusses the importance of communication between professionals in palliative care. It begins by describing the evidence base that shows that patient and provider outcomes are significantly related to the effectiveness of interprofessional communication. Next it outlines the principles of good interprofessional communication including the importance of adopting an attitude of curiosity, recognizing that communication happens at several levels simultaneously, and acknowledging the importance of skilful conflict management. The following section on communication among members of an interdisciplinary team (IDT) reviews the barriers to good IDT communication, including team organization, provider hierarchy, and professional identity. The next section on communication between palliative consultants and other clinicians discusses consultation etiquette and its evidence base; highlights some of the particular challenges faced by palliative care consultants; and describes strategies for good communication in palliative care consultation. The chapter concludes with a description of future directions in the study and promulgation of interprofessional communication and the role that the field of palliative care can play. more...

It is well known that clinicians experience distress and grief in response to their patients' suffering. Oncologists and palliative care specialists are no exception since they commonly experience patient loss and are often affected by unprocessed grief. These emotions can compromise clinicians' personal well-being, since unexamined emotions may lead to burnout, moral distress, compassion fatigue, and poor clinical decisions which adversely affect patient care. One approach to mitigate this harm is self-care, defined as a cadre of activities performed independently by an individual to promote and maintain personal well-being throughout life. This article emphasizes the importance of having a self-care and self-awareness plan when caring for patients with life-limiting cancer and discusses validated methods to increase self-care, enhance self-awareness and improve patient care. more...

Patients facing serious or life-threatening illness experience challenges to their psychological, social, and spiritual lives as well as to their physical function and comfort. Physicians may be accustomed to focusing on the biomedical aspects of illness, but they have a critical role in assessing the patient's psychosocial issues to identify sources of distress and help implement a plan for mitigating them. An appropriate psychosocial assessment requires a methodical and rigorous approach and includes assessment of any psychosocial issue affected by or affecting a patient's experience of illness. This chapter outlines a structured approach to addressing psychosocial issues by discussing (1) the doctor-patient relationship; (2) coping with illness; (3) family dynamics and caregiving; (4) ethnic and cultural issues; (5) religious, spiritual, and existential issues; (6) mental health issues, including adjustment disorder, depression, anxiety, personality disorders, aberrant drug behaviors, and major mental health issues; and (7) grief and bereavement. Tables outline psychosocial assessment questions, factors predisposing patients with serious illness to depression, risk factors for suicide in patients with terminal illness, and classes of antidepressants, anxiolytics, and sedatives. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire is provided, as well as a list of Web sites with further resources about psychosocial issues in serious illness. This chapter contains 1 highly rendered figure, 6 tables, 216 references, and 5 MCQs. more...

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. more...

As inpatient palliative care units (IPCUs) have become more widespread, experience grows regarding the patients for whom they are best suited. We report here on the use of an IPCU in the treatment of several individuals with comorbid psychiatric and advanced life-threatening illness during a 1-year period. At least four categories of such patients—those with suicide risk, dangerous noncompliance, anxiety with substance dependence and diagnostic dilemmas—may benefit uniquely from the individualized, whole person, interdisciplinary approach of an IPCU. Effective referral and comanagement of these patients requires both close collaboration between psychiatric and palliative care clinicians, and awareness of the advantages and limitations of alternatives such as inpatient medical and psychiatric units. more...

performance and behavior at work. Effective physician leadership is instrumental to improved patient satisfaction, reduced length of stay, and better integration of clinical care across service lines. To be effective, physician leaders must master multiple clinical and leadership competencies, including interpersonal skills. When leaders learn to use interpersonal skills, they are able to apply them in a wide variety of specific activities, including leading teams, coaching, and managing conflict. This preconference program is offered in partnership with the American Association for Physician Leadership. This session applies to all physician leaders and practice settings looking to increase their effectiveness as a team leader. Primary leadership competencies addressed in this program include interpersonal skills, communication skills, and the ability to convey a clear, compelling vision. more...

different mindset than traditional wound care yet is based on the same fundamental scientific principles. This workshop presents an approach to palliation in wound care that involves being able to properly assess a wound and determine if palliation is appropriate, developing a comprehensive strategy for palliation of various types of wounds, and managing symptoms of chronic wounds, especially pain and odor. The many benefits of an effective palliative wound program, including improved quality of life and achieving the goal of healing the whole person, will be addressed. The emphasis will be on palliative wound care helping to achieve hospice goals for the patient. more...

I stood quietly in the middle of the circle, with 4 or 5 friendly hands on my belly. Nothing in my career to that point had prepared me for this moment, but I found myself relaxing and enjoying the... more...

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. more...

preferences and enabling the patient to continue to hope. Methods: We developed a case and scoring system for an OSCE. The OSCE was administered to 11 interprofessional fellows at the beginning and end of fellowship. The case and scoring system were adjusted based on our observations and fellow feedback during this pilot phase so that the scores captured the desired expertise. Statistical analysis was performed on a program level to more...

Objectives Learn how physicians in specific countries provide palliative care to their patient populations often with limited resources Understand specific cultural and political challenges to developing palliative care clinical, educational and research programs Describe roles of different health care providers practicing palliative care and how they meet the needs of their local populations Please join AAHPM’s International Scholars for a panel discussion. Each scholar will present for 10-15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin. more...

Objectives 1. Define the components of a research-based definition of being a ‘‘good’’ parent. 2. Describe strategies for eliciting parental perspectives on being a ‘‘good’’ parent. 3. Define ways clinicians can support parents to achieve their definition of being a’’good’’ parent. Parents confronted with the suffering of their children as a result of life-threatening illness and injury struggle to make decisions for their child that honors their child’s humanness and quality of life and preserves parental integrity. Clinicians similarly struggle with reconciling often disparate understandings of goals and treatment options with parental requests for continuation or limitations of treatment modalities. Without a framework for exploring these perspectives conflict occurs relationships begin to fracture and distress ensues. When clinicians can understand the ways that parents define their role as a ‘‘good parent,’’ new opportunities for understanding communication and collaboration arise. This researchebased, clinically supported interactive workshop will present the findings from qualitative interviews from parents with children born with life-threatening conditions in the NICU and parents who have made end-of-life decisions for children with cancer. A multi-component definition of ‘‘good parent’’ from the perspective of parents and parental suggestions about the roles that clinicians can play in helping them to achieve their definition of being a ‘‘good parent’’ for their seriously ill or dying child will be presented. These findings will be augmented with video clips of parents sharing their views on being a good parent. Workshop participants will engage in thematic analysis of the content of the videos and reflection on cases that involve the interplay between conceptions of what it means to be a ‘‘good’’ parent and a ‘‘good’’ clinician in the care of seriously ill or dying children. Participants will gain (1) a working grasp of the concept of being a good parent to a seriously ill or dying child, (2) clarity on how to clinically elicit the parental perspective on being a good parent of a child, and (3) a perspective on how to apply the concept of good parent to their own clinical practice. more...

Peer Mentoring: An Innovative Model for Professional Advancement in Hospice and Palliative Medicine (320) Rachelle Bernacki, MD MS, Dana Farber Cancer Institute, Boston, MA. Sandra SanchezReilly, MD, University of Texas Health Science Center at San Antonio and STVHCS, San Antonio, TX. Elise Carey, MD, Mayo Clinic Rochester, Rochester, MN. Jane DeLima Thomas, MD, Harvard Medical School, Boston, MA. Jen Kapo, MD, University of Pennsylvania, Philadelphia, PA. Laura Morrison, MD, Baylor College of Medicine and The Methodist Hospital, Houston, TX. VJ Periyakoil, MD, Stanford University, Palo Alto, CA. Lynn O’Neill, MD, Mount Sinai School of Medicine, New York, NY. (All speakers have disclosed no relevant financial relationships.) more...