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1. Understand the inpatient respite care experience via lessons learned from interviews with ALS patients and caregivers including perceptions, barriers to use, and how insights may apply to inpatient respite care for other patient populations. 2. Discuss the collaborative development of a patient-centered inpatient respite care admission checklist, designed to enhance communication between patients, caregivers and the inpatient interdisciplinary team. Providing inpatient respite care for ALS patients is uniquely challenging due to specialized equipment and skills which may be unfamiliar to inpatient providers. An admission checklist was collaboratively developed with ALS patients, caregivers and an interdisciplinary hospice team to address these challenges. This tool may benefit patients with neurodegenerative diseases and communication challenges, improving the quality of inpatient respite care. Provision of inpatient hospice (IPU) respite care for patients with amyotrophic lateral sclerosis (ALS) presents unique challenges. As ALS progresses, care requires specialized equipment and advanced caregiver skills, placing a substantial burden on caregivers. Technologies such as eye-tracking communication devices and portable ventilators, often integral for ALS patients, are rarely used in the IPU setting. The gap between ALS patient/caregiver experiences and expectations, and that of IPU interdisciplinary teams, can present significant obstacles to high-quality care for this population which could greatly benefit from respite services. We conducted a quality improvement project to improve inpatient respite care for ALS patients. Initial interviews with the caregiver of the patient who inspired this project, and their bedside nurse, pinpointed communication breakdowns as the main root cause of a difficult IPU respite experience and identified the intake process as a key improvement opportunity. An interview guide was developed to characterize inpatient respite care perceptions, experiences, and barriers to use. Semi-structured, in-depth interviews were conducted with 4 patient-caregiver dyads and 2 caregivers of patients who had passed, and field notes taken. Themes identified within and between interviews guided an interdisciplinary hospice team in developing an inpatient admission checklist to align patient and caregiver expectations with those of staff. The checklist was iteratively refined based on feedback from patients, caregivers, and staff. An IPU admission checklist was collaboratively developed by an interdisciplinary hospice team, ALS patients and their caregivers. This checklist addresses unique pre-admission logistics for ALS patients including medical equipment, home routine integration, and interventions for addressing common sources of patient distress/discomfort. A patient-centered IPU respite admission checklist can help align expectations between patients with complex medical needs, caregivers, and respite care providers. It may benefit not only ALS patients, but also those with other neurodegenerative diseases and communication challenges. Communication / Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]

1. To use a case-based, interactive approach to facilitate recognition of EPS induced by antipsychotics, distinguish EPS from other common causes of agitation, and recommend management of EPS in the context of hospice and palliative medicine. 2. Discuss a practical intervention that clinicians can readily integrate into their clinical settings to improve antipsychotic prescribing practices to minimize medication-related adverse effects. Common antipsychotic side effects may be misdiagnosed as agitation near the end of life, resulting in a catch-22 of inappropriate antipsychotic dose escalation to treat medication-induced agitation, thus worsening patient discomfort. A practical and brief educational intervention can improve prescriber recognition of antipsychotic side-effects, reducing these medication-related adverse events and improving end-of-life care. Antipsychotics are valuable tools for palliating agitation, a common symptom near the end of life. However, over one-third of individuals treated with antipsychotics experience uncomfortable extrapyramidal side effects (also known as extrapyramidal symptoms or EPS). EPS, a consequence of dopamine blockade, encompasses a spectrum from drug-induced parkinsonism to involuntary movements to akathisia (a subjective sense of restlessness). EPS may be underrecognized in the palliative care setting, leading to a catch-22 of escalating antipsychotic doses for what is actually EPS-induced agitation. This risk is compounded by the advanced age and antipsychotic inexperience of most hospice patients, along with the common use of haloperidol, the antipsychotic with the highest EPS risk. In a series of four inpatient hospice cases, EPS secondary to haloperidol were misdiagnosed as worsening agitation, prompting inappropriate dose escalation. To address this issue, high-yield antipsychotic use recommendations were compiled and disseminated to eight inpatient hospice providers. Subsequently, all providers completed a survey evaluating the impact of the recommendations on clinical practice and patient symptoms. In each patient case, discontinuation of haloperidol resolved agitation, supporting EPS as the underlying etiology. As a result of the prescribing recommendations, the inpatient hospice admission orders were modified to reduce the dose and frequency of PRN haloperidol for agitation. Survey Results: overwhelmingly indicated that the intervention influenced antipsychotic prescribing practices and increased clinician confidence in EPS assessment. All prescribers expressed a strong desire for additional training on this subject for themselves and bedside nurses. EPS are common and underrecognized antipsychotic side effects that can precipitate inappropriate dose escalation and worsen discomfort near the end of life. Brief educational interventions can prime clinicians to consider EPS on the differential diagnosis of agitation refractory to antipsychotics and provide knowledge to treat these symptoms effectively. Pharmacotherapeutics / Pharmacopalliation / Managing Suffering and Distress [ABSTRACT FROM AUTHOR]