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Breast cancer patients may not be well-informed about palliative care, hindering its integration into cancer self-management.The aim of this study was to test Managing Cancer Care: A Personal Guide (MCC-PT), an intervention to improve palliative care literacy and cancer self-management.This was a single-blind pilot randomized controlled trial to evaluate the feasibility/acceptability and intervention effects of MCC-PT on palliative care literacy, self-management behaviors/emotions, and moderation by demographic/clinical characteristics. We enrolled 71 stages I to IV breast cancer patients aged at least 21 years, with6-month prognosis at an academic cancer center. Patients were randomized to MCC-PT (n = 32) versus symptom management education as attention-control (n = 39). At baseline, 1 month, and 3 months, participants completed the Knowledge of Care Options Test (primary outcome), Control Preferences Scale, Goals of Care Form, Medical Communication Competence Scale, Measurement of Transitions in Cancer Scale, Chronic Disease Self-efficacy Scale, Hospital Anxiety and Depression Scale, and the Mishel Uncertainty in Illness Scale.Mean participant age was 51.5 years (range, 28-74 years); 53.5% were racial/ethnic minority patients, and 40.8% had stage III/IV cancer. After adjusting for race/ethnicity, MCC-PT users improved their palliative care literacy with a large effect size (partial η2 = 0.13). Patients at late stage of disease showed increased self-management (partial η2 = 0.05) and reduced anxiety (partial η2 = 0.05) and depression (partial η2 = 0.07) with medium effect sizes.Managing Cancer Care: A Personal Guide is feasible and appears most effective in late-stage cancer. Research is needed to elucidate relationships among cancer stage, race/ethnicity, and self-management outcomes.Integration of palliative care into cancer care can assist in creation of appropriate self-management plans and improve emotional outcomes.

Self- and family management (SFM) refers to patients’ and family caregivers’ activities to co-manage illness. Two barriers to SFM are low palliative care literacy and lack of goals of care communication, which potentially result in SFM activities that are unsupportive of patients’ goals. Managing Cancer Care: A Caregiver’s Guide (MCC-CG) aims to improve palliative care literacy and communication within a SFM training program. In this pilot randomized trial, we enrolled breast cancer family caregivers and collected data at 0, 1, and 3 months on palliative care literacy, SFM engagement, communication, transitions management, uncertainty, caregiver burden, and caregiver competence/personal gain. Participants ( n = 35) had a mean age of 54 (range: 18–81) and were 66% white and 34% racial/ethnic minorities. Intervention participants improved their palliative care literacy and SFM engagement, reduced uncertainty and caregiver burden, increased competence/personal gain, and had more goals of care conversations over time. MCC-CG has preliminary efficacy, warranting further study.

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.

Background COVID-19 presents unique challenges to the care of hospitalized older adults, including fractured lines of communication and uncertainty surrounding long term trajectories in cognition and function. Geriatric medicine and palliative care clinicians bring specialized training in facilitating communication in the face of uncertainty. Insurance expansion of virtual visits enabled inpatient virtual consultation, which can preserve personal protective equipment and minimize exposure to clinicians. We examined changes in goals of care and code status following an inpatient virtual consultation with geriatric medicine and palliative care clinicians. Methods This was an observational case series study performed at a large tertiary Academic Hospital. The study population included 78 patients aged 65 years and older, hospitalized with COVID-19 who had an inpatient consultation completed by geriatric medicine or palliative care clinicians between April 9, 2020 through May 9, 2020. The intervention was targeted, virtual geriatric medicine or palliative care consultation. All patients admitted to a medical floor with COVID-19 were screened four days a week and if a patient was over the age of 65, the medical team was offered a consultation by geriatric medicine (ages 80 and above) or palliative care (ages 65-79). Consultation included medical record review, telephone conversations with clinicians and nurses, telephone or video conversations with patients and/or surrogate decision-makers and collaborative case review on daily virtual huddles with an interprofessional team of geriatric medicine and palliative care clinicians. Descriptive statistics were applied to categorize outcomes after chart abstraction. Results Following consultation, 24 patients (31%) patients changed their code status to less invasive interventions. Of patients who were FULL CODE at the time of consultation (n=42), 2 (4.8%) transitioned to DNR only and 16 (38.1%) transitioned to DNR/DNI after consultation. While 8 patients (10.3%) utilized intensive care unit (ICU) level of care prior to consultation, 6 (7.6%) patients utilized ICU after consultation. After consultation, 11 (14.1%) patients were referred to hospice. Conclusions Given uncertain trajectories in older adults hospitalized with COVID-19 and variability in patient preferences, virtual goals of care geriatric medicine and palliative care consultations should be considered as a key component of COVID-19 hospital protocols.

To determine to what extent did health care workers experience the pandemic as a severe stress event.This cross-sectional evaluation of 8299 health care workers, representing a 22% response rate, utilized machine learning to predict high levels of escalating stress based on demographics and known predictors for adverse psychological outcomes after trauma.A third of health care workers experienced the pandemic as a potentially traumatic stress event; a greater proportion of health care workers experienced high levels of escalating stress. Predictive factors included sense of control, ability to manage work-life demands, guilt or shame, age, and level of education. Gender was no longer predictive after controlling for other factors. Escalating stress was especially high among nonclinical academics and clinical private practitioners.Findings suggest adverse effects on total worker health, care quality, professionalism, retention, and acute and chronic mental health.

Consequent to increasing COVID-19 infection rates, the Palliative Care (PC) service at a large New England hospital shifted from in-person to telehealth-delivered PC (TPC).We compared the quality of TPC to in-person PC during the early COVID-19 pandemic.We conducted an electronic health record review of PC consultations of patients hospitalized during three periods: pre-COVID January, 2020-February, 2020 (in-person); peak-COVID March, 2020-June, 2020 (majority TPC); and post-peak September, 2020-October, 2020 (majority in-person). We examined the relationship between these periods and PC delivery characteristics and quality measures using descriptive and bivariate statistics.Of 377 patients, 50 were pre-COVID (TPC=0%), 271 peak-COVID (TPC=79.3%), and 56 post-peak (TPC2%) (representation of PC consult: pre- and post-peak=samples; peak-COVID=all consults). Mean age was 69.3 years (standard deviation=15.5), with 54.9% male, 68.7% White, and 22.8% Black. Age and sex did not differ by period. PC consultations were more likely for goals of care (pre=30.0% vs. peak=53.9% vs. post=57.1%; P = 0.005) or hospice (4.0% vs. 14.4% vs. 5.4%, P = 0.031) during peak-COVID compared to pre-COVID. Rates of assessment of physical (98.0% vs. 63.5% vs. 94.6%, P0.001) and psychological symptoms (90.0% vs. 33.1% vs. 67.9%, P0.001) were lower during peak relative to pre-COVID and post-peak periods. There were no differences in assessment of patients' social needs, family burden, or goals of care across periods.The PC service provided high-quality inpatient PC using TPC despite significant strain during the early COVID-19 pandemic. Developing and testing strategies to promote comprehensive symptom control using TPC remains a priority to adjust to potential unmet PC needs.

The burden of the COVID-19 pandemic upon healthcare workers necessitates a systematic effort to support their resilience. This article describes the Yale University and Yale New Haven Health System effort to unite several independent initiatives into a coherent integrated model for institutional support for healthcare workers. Here, we highlight both opportunities and challenges faced in attempting to support healthcare workers during this pandemic.

BACKGROUND: Certain cancer types and subsequent treatment can cause or worsen pain and emotional distress, leading to functional limitation, particularly among a growing population of older adults with cancer.. METHODS: We constructed a national sample of older adult Medicare beneficiaries with cancer using the 2007– 2012 Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D enrollment and prescription claims data. MHOS survey responses described functional limitations due to pain and emotional distress. Using multivariable logistic regression, we estimated the association between participant characteristics and patient-reported functional limitation due to pain and emotional distress and subsequent prescription medication use. RESULTS: Among 9,105 older adults with cancer, aged 66–102 years (y), 68.6% reported moderate to severe functional limitation due to pain, and 48.3% reported moderate to severe functional limitation due to emotional distress. Nearly 10% reported severe functional limitation due to co-occurring symptoms of pain and emotional distress. Significant predictors of severe functional limitation due to co-occurring symptoms included age ≥80y (ref: 66–69y, adjusted relative risk (aRR): 1.74; 95% confidence interval (CI) 1.39–2.18, p

ObjectivesWe aimed to explore the association between receiving an inpatient palliative care consultation and hospital outcomes, including in-hospital death, intensive care unit (ICU) use, discharge to hospice, 30-day readmissions and 30-day emergency department (ED) visits.MethodsWe conducted a retrospective chart review of Yale New Haven Hospital medical oncology admissions from January 2018 through December 2021, with and without inpatient palliative care consultations. Hospital outcome data were extracted from medical records and operationalised as binary. Multivariable logistic regression was used to estimate ORs for the association between number of inpatient palliative care consultations and hospital outcomes.ResultsOur sample included 19 422 patients. Age, Rothman Index, site of malignancy, length of stay, discharge to hospice, ICU admissions, hospital death and readmissions within 30 days differed significantly between patients who received versus did not receive a palliative care consultation. On multivariable analysis, receiving one additional palliative care consultation was significantly associated with higher odds of hospital death (adjusted OR=1.15, 95% CI 1.12 to 1.17) and discharge to hospice (adjusted OR = 1.23, 95% CI 1.20 to 1.26), and lower odds of ICU admission (adjusted OR=0.94, 95% CI 0.92 to 0.97). There was no significant association between palliative care consultations and readmission within 30 days or with ED visits within 30 days.ConclusionInpatients receiving palliative care had increased likelihood of hospital death. However, when controlling for significant differences in patient presentation, patients had nearly 25% greater odds of discharge to hospice and less odds to transition to ICU level of care.

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.

Context Chronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT). Objective Our objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges. Methods We recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment. Results Of 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7–8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend nonpharmacologic and nonopioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine. Conclusion Palliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.

Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p

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.

Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.

Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD.To conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD.A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphine-naloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021.Of 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%) participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years.The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.

CONTEXT: Concerns about the adequacy of pain management among older adults are increasing, particularly with restrictions on opioid prescribing. OBJECTIVES: To examine associations between prescription pain medication receipt and patient-reported pain interference in older adults with and without cancer. METHODS: Using the 2007–2012 Surveillance Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D prescription claims, we selected MHOS respondents (N = 15,624) aged ≥ 66 years, ≤ 5 years of a cancer diagnosis (N = 9105), or without cancer (N = 6519). We measured receipt of opioids, non-steroidal antiinflammatory drugs, and antiepileptics, and selected antidepressants within 30 days prior to survey. Patient-reported activity limitation due to pain (pain interference) within the past 30 days was summarized as severe, moderate, or mild/none. Logistic regression using predictive margins estimated associations between pain interference, cancer history, and pain medication receipt, adjusting for socio-demographics, chronic conditions, and Part D low-income subsidy. RESULTS: Severe or moderate pain interference was reported by 21.3% and 46.1%, respectively. Pain medication was received by 21.5%, with 11.6% receiving opioids. Among adults reporting severe pain interference, opioid prescriptions were filled by 27.0% versus 23.8% (p = 0.040) with and without cancer, respectively. Over half (56%) of adults reporting severe pain in both groups failed to receive any prescription pain medication. CONCLUSIONS: Older adults with cancer were more likely to receive prescription pain medications compared with adults without cancer; however, many older adults reporting severe pain interference did not receive medications. Improved assessment and management of pain among older adults with and without cancer is urgently needed.

Background Despite evidence that palliative care increases quality and length of life, many patients and families remain uninformed about its nature and benefits. The purpose of this study is to test a psycho-educational intervention, Managing Cancer Care : A Personal Guide ( MCC ), intended to improve breast cancer patients' knowledge of palliative care and to facilitate its timely integration into cancer self-management. Methods Aims are to: 1) evaluate the effects of MCC on patients' knowledge of palliative care; 2) examine preliminary effects of MCC on patients' behaviors (role in self-management, engagement in goals of care conversations, medical communication, management of transitions, health care utilization), and feelings (self-efficacy, anxiety, depression, uncertainty); and 3) evaluate protocol feasibility and acceptability. An exploratory aim is to investigate how demographic and clinical factors may moderate intervention effects, with emphasis on differences in use and outcomes among minority participants. We plan to enroll 60 patients and their family caregivers with 50% minority participation. The intervention group receives MCC; the attention-control group receives a Symptom Management Toolkit. We collect data at baseline, one, and three months. Discussion This study will inform a large scale trial of MCC. It is challenging for patients with breast cancer, their family caregivers, and providers to make choices that include palliation alone or in combination with potentially curative treatment. MCC may help address this challenge by giving patients the information, skills, and confidence to better self-manage breast cancer. Results may help to establish palliative care as a mainstay of self-management interventions targeting serious illness. Trial registration ClinicalTrials.gov Identifier NCT02148575 (date registered: 5.21.14; date first patient enrolled: 7.15.14)

Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. Consultative palliative care models may be required for more complex palliative care needs including symptom management, medical decision making, and bereavement. This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.

Lung cancer is the leading cause of death due to malignancy. Although lung cancer mortality has been decreasing in recent years, it remains substantially higher than other causes of cancer death. Median survival for patients with locally advanced non-small cell lung cancer, defined as lung cancer involving regional lymph nodes, is estimated to be approximately 10 to 17 months, and median survival for patients with metastatic disease is only 6 to 9 months. In addition, patients with advanced lung cancer often experience debilitating symptoms and poor quality of life. Pain, dyspnea, and fatigue are most frequently reported and affect at least 65% of patients with advanced lung cancer. Given this burden of symptoms and high mortality, patients and their families facing a diagnosis of advanced lung cancer are in need of support. Palliative care, with its focus on addressing the emotional, physical, and spiritual sources of suffering utilizing the expertise of an interdisciplinary team, can provide this comprehensive support. This review describes the role of supportive and palliative care integrated into the treatment of patients with a diagnosis of advanced lung cancer with sections focused on the evaluation and treatment of pain and dyspnea, approaches to challenging communication tasks, and the support of caregivers who care for patients with advanced lung cancer.

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.

Palliative care (PC) programs utilize chaplains to address patients' spiritual care needs; however, there is no comprehensive description of chaplaincy in PC programs nationally.To describe chaplains working in PC across the United States, including their integration on the PC team and visit content.National online survey conducted February-April 2015.We invited participation from hospital-based chaplains belonging to four national professional chaplain associations who spent 15% or more of their working hours with PC teams. Measure(s): We developed a 41-item survey to investigate main outcomes of chaplain demographics, practice information, integration into the PC team, and visit content.531 valid responses were received. We report on respondents who were full-time chaplains (n = 382). Almost half were women (46%), and the majority was Protestant (70%). The average number of PC patients seen per day was 5.2 (SD = 3.5, range 1-30). Half (52%) reported frequently participating in PC rounds. Primary chaplain activities were relationship building (76%), care at the time of death (69%), and helping patients with existential issues or spiritual distress (49%). Over half (55%) reported addressing goals of care 60% of the time or more.This survey provides the first description of chaplains working in PC across the United States. We describe chaplains' critical role in attending to relationship building, care for the dying, and goals of care conversations. Our results highlight how the chaplains' level of involvement in PC affects the content of their visits. Our study suggests that when chaplains are more involved in PC teams, they provide more comprehensive support to PC patients and their families.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. The NCCN Guidelines are intended to provide guidance to the primary oncology team on the integration of palliative care into oncology. The NCCN Palliative Care Panel's recommendations seek to ensure that each patient experiences the best quality of life possible throughout the illness trajectory. Accordingly, the NCCN Guidelines outline best practices for screening, assessment, palliative care interventions, reassessment, and after-death care.

181 Background: Early palliative care referral has proven useful in reducing chemotherapy given to cancer patients in the last 30 days of life. We designed a program to help train primary oncologists in having goals of care (GOC) conversations with patients. We conducted this initiative across the Yale Cancer Center/Smilow Cancer Hospital Care Centers (SCHCCs). The aim was to determine whether simple tools could be used by general oncologists to improve patient care, as measured by chemotherapy utilization at the end of life. Methods: A multidisciplinary team completed process mapping and cause-and-effect barrier analysis regarding GOC discussion with patients. Five interventions (PDSA cycles) were chosen to improve physician skills with GOC conversations. SCHCC physicians (n = 21) utilized each tool on 5 patients per month from July to December 2017. Interventions included asking patients simple questions regarding GOC, using the phrase “allow natural death”, giving patients a “serious conversation starter kit”, and identifying patients with poor prognosis. A GOC survey was administered to physicians at baseline and after completion of the initiative. Data on chemotherapy and immunotherapy given during the last 30 days of life for SCHCC patients were measured. Results: SCHCC physicians who completed the baseline survey (n = 17) were 27% likely to discuss GOC repeatedly during the course of illness, compared to 70% post intervention (n = 10), while 88% felt comfortable discussing GOC at baseline compared to 100% after intervention. Chemotherapy within 30 days of death was administered to 30.3% patients (n = 109) in Q1 2017 and 23.3% in Q3 (n = 103) in the Care Centers. Of note, immunotherapy administered within 30 days of death was 6.4% in Q1 and 6.7% in Q3. Conclusions: A quality initiative focused on providing oncologists with simple tools to improve GOC conversations led to decrease from 30.3% to 23.3% of patients receiving chemotherapy within the last 30 days of life. Survey respondents felt more comfortable in discussing GOC and were more likely to do this throughout the course of illness. This pilot suggests that palliative care training of primary oncologists is feasible and may help to decrease unnecessary treatment at the end of life.

15 Background: Concerns about the adequacy of pain management among older adults are increasing. We examined calendar year (CY) trends in prescription medication (Rx) use by older adults with and without cancer who reported pain interference with normal activities. Methods: Using the 2007-2012 SEER-Medicare Health Outcomes Survey (MHOS) database with a unique linkage to Part D prescription claims data, we selected MHOS participants with Part D coverage who were within 5 years of cancer diagnosis or without cancer history. We used Rx claims to characterize use of opioids, non-opioid analgesics, local anesthetics and anti-epileptics during the 90 days post survey. Participant reported pain-related activity limitations within the past 30 days (pain interference) were summarized as severe, moderate, or none. We applied multivariable logistic regression to determine associations of Rx use with CY, cancer status, and pain interference, controlling for socio-demographics, chronic conditions, plan type and Part D Low Income Subsidy. Adjusted outcome levels were predicted based on the regression coefficients. Results: In the total sample (N = 15,624), pain Rx was used by 30%, with 20% receiving opioids. Severe or moderate pain interference with activities was reported by 23% and 46%, respectively. Among respondents with cancer (N = 9,105), 49% reporting severe (28% moderate) pain interference received any pain Rx; 37% & 18% used opioids, respectively. For those without cancer, adjusted pain Rx use rates were significantly lower in all categories. Pain Rx increased over CY for cancer respondents with moderate pain (25% in 2008 to 31% in 2012; p = .017), but not for those reporting severe pain interference. In addition, pain Rx increased over CY for the cohort without cancer with no pain interference (11% in 2008 to 14% in 2012; p = .027). Conclusions: Despite increased focus on symptom management, the majority of older adults who experienced moderate or severe pain interference did not have Rx for pain management. Efforts to identify and target unmet supportive care needs for Medicare beneficiaries, with and without cancer, are necessary to further improve quality of life.

10105Background: There is increasing concern about the adequacy of symptom management among older adults with cancer. We examined patterns and predictors of pain and emotional distress after a canc...

We performed semistructured interviews with 30 family members of patients with advanced dementia to identify the factors that facilitate or hinder advance planning by persons with dementia. All interviews were analyzed using qualitative data analysis techniques. The majority (77%) of family members reported that their relative had some form of written advance directive, and at least half reported previous discussions about health care preferences (57%), living situation or placement issues (50%), and finances or estate planning (60%) with the patient. Family members reported some themes that prompted planning and others that were barriers to planning. Events that most often triggered planning were medical, living situation, or financial issues associated with a friend or family member of the patient (57%). Barriers to planning included both passive and active avoidance. The most common form of passive avoidance was not realizing the importance of planning until it was too late to have the discussion (63%). The most common form of active avoidance was avoiding the discussion (53%). These data suggest potentially remediable strategies to address barriers to advance planning discussions.

Patients typically receive hospice care only in the last days or weeks of life, and there is widespread agreement among experts that patients enroll in hospice too late. However, it is not known whether patients and their families believe that they are enrolling in hospice too late.Prospective interview study.Not-for-profit, Medicare-certified hospice.Patients and families recruited at consecutive hospice enrollment visits.Interviews at the time of hospice enrollment and 1 month after death or discharge from hospice assessed patients' and families' perceptions of the timing of hospice enrollment ("too soon," "too late," "at about the right time").Interviews were conducted at 274 enrollment visits. Very few patients (1/85; 1%) and family members (12/261; 5%) said that they believed they were enrolling in hospice too late. In follow-up interviews with families after the patient's death or discharge, families were more likely to believe that enrollment was too late (n = 38/218; 17%; sign test p.001). Families who believed they had enrolled too late had shorter lengths of stay in hospice compared to those who said that enrollment was too soon or at the right time (median 10 vs. 24 days; rank-sum test p0.001).Despite late enrollment in hospice and very short lengths of stay, most patients and families believe that they are enrolling in hospice at the right time.

Hospices provide care to patients with a wide range of prognoses, and must develop care plans that anticipate each patient's likely illness trajectory. However, the tools available to guide prognostication and care planning in this population have limited data to support their use. For instance, one of the most widely-used prognostic tools, the Palliative Performance Scale (PPS), has been studied primarily in inpatient settings and in patients with cancer. Its prognostic value in a heterogeneous US hospice population is unknown.The goal of this study was to evaluate the prognostic value of the PPS as a predictor of mortality in a heterogeneous hospice population, and to determine whether it performs equally well across diagnoses and sites of care.Prospective cohort study using existing medical records.This study was conducted at a large community hospice program, and included all patients enrolled in hospice during the study period.Each patient's PPS score was recorded at the time of enrollment and patients were followed until death or discharge from hospice.A total of 466 patients enrolled in hospice during the study period. The PPS score was a strong independent predictor of mortality (log rank test of Kaplan Meier survival curves p0.001). Six-month mortality rates for 3 PPS categories were 96% (for PPS scores 10-20), 89% (for PPS scores 30-40), and 81% (for PPS scoresor =50). Evaluation of interaction terms in Cox proportional hazards models demonstrated a stronger association between PPS score and mortality among nursing home residents and patients with non-cancer diagnoses. Analysis of the area under receiver operating characteristic curves demonstrated strong predictive value overall, with somewhat greater accuracy for nursing home residents and patients with noncancer diagnoses.The PPS performs well as a predictor of prognosis in a heterogeneous hospice population, and performs particularly well for nursing home residents and for patients with non-cancer diagnoses. The PPS should be useful in confirming hospice eligibility for reimbursement purposes and in guiding plans for hospice care.

Hospice has become the major provider of comprehensive end-of-life care in the United States, but is underutilized by African American patients. It is likely that whatever factors are responsible for lower rates of hospice utilization among African Americans also lead to lower rates of return to hospice after discharge, but this is not known.To determine whether African American patients who leave hospice are less likely to return before death.Retrospective cohort study.University-affiliated hospice.All patients discharged after a first admission.All patient characteristics were defined by abstraction of electronic medical records at the time of hospice discharge.Of 358 discharged patients, 98 (27%) were decertified and 260 (73%) left voluntarily. Ninety-six patients returned to hospice during the study period. In bivariate analysis, African Americans were less likely to return than were other patients (odds ratio (OR) 0.47, 95% CI: 0.28-0.80; p = .005). In a multivariable logistic regression model, African American ethnicity was independently associated with a decreased likelihood of return.Ethnic disparities in hospice utilization may extend even to those patients who do enroll in hospice. African Americans who leave hospice during their first admission and their families may be less likely to have access to the comprehensive services that hospice programs provide near the end of life, including intensive nursing care, pain and symptom management, and education.

Objectives: To determine whether families of patients who enroll in hospice near the end of life believe that they receive less benefit from hospice services than families of patients who enroll earlier. Design: Semistructured interviews at the time of hospice enrollment and 1 month after the patient's death. Setting: This study was conducted at the Hospice of Lancaster County, Lancaster, PA, over a 12-month period spanning 2003–2004. Participants: First-time hospice admissions. Measurements: Interviews assessed the anticipated helpfulness of six hospice services (enrollment interviews) and the actual helpfulness of the same services (follow-up interviews). Results: Length of stay in hospice was associated with families' reports of the number of services provided (Spearman rho=0.34, P

OF ALL THE TOPICS TO WHICH oncologists, palliative care clinicians and ethicists have devoted their attention, few raise as much heated debate as does the discussion of phase I trials of potential cancer therapies. Commentators point to an array of clinical and ethical challenges, including the low chance of potential benefit, and patients’ overly optimistic expectations of benefit.1,2 It is fair to say that these issues have generally proved to be a strongly divisive force, and one that separates phase 1 investigators from clinicians whose goal is the relief of suffering. This separation is frustrating for many palliative care clinicians, who see phase 1 trials as a series of missed opportunities to provide good end of life care.3 At the heart of this divide, and the source of much of the frustration that it causes, is the assumption that subjects who participate in phase 1 trials must give up quality palliative care. That is, there is a widespread belief that these subjects must forgo a coordinated plan of care that focuses on anticipatory guidance, spiritual and psychological support, and symptom management. In a sense, a large part of the debate about phase 1 trials stems from the assumption that patients must choose between trial participation and palliative care.3 Manish Agrawal and Marion Danis make a clear and convincing case that this dichotomy is false. They argue that it is a dichotomy that makes little sense, either in terms of goals for care, or in terms of good clinical practice. More importantly, they suggest, by clinging to the idea that we must either offer our patients palliative care or participation in phase 1 trials, we are denying them valuable care and doing them a grave disservice. The solution they propose—and it is one that is long overdue—is that the communities of phase 1 investigators and palliative care clinicians should work together to provide quality care to subjects who enroll in phase 1 trials. This solution has a great deal to recommend it, and growing evidence to support its feasibility. For instance, at the National Institutes of Health, Dr. Ann Berger has established a highly successful palliative care consultation service for subjects enrolled in early phase trials. Although not widely emulated yet, her service describes precisely the sort of collaboration that Agrawal and Danis propose. A more aggressive form of collaboration may be feasible as well. A recent nationwide random survey of hospices and phase 1 investigators found that the vast majority of both groups believed that patients should be allowed to enroll in phase 1 trials and hospice simultaneously.4 But this solution raises significant problems as well. Many institutions lack the resources needed to provide comprehensive palliative care, and therefore research protocols may become the institution’s only formal mechanism to provide palliative care services. These research-based palliative care services have the potential to become a “safety net” to meet an institution’s palliative care needs. This development could have two important ethical consequences. First, if good palliative care is only available, or most readily available, to pa

Identify key members of a steering committee for a system-wide palliative and emergency care collaborative initiative. Identify the challenges of facilitating change across a health system of three hospitals with different institutional cultures and hospital-specific goals. There is growing recognition that the collaboration of palliative care and emergency medicine teams caring for complex patients

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.

e18198Background: Hospitalizations in patients with cancer are common near the end-of-life, associated with poor prognosis and often against patients’ expressed wishes. The Rothman Index (RI) is a ...