The Effects of Integrative Palliative Oncology on Hospital Time, Hospice Referrals, and Advanced Care Planning

Background: Integrative palliative oncology incorporates mental, physical, and familial aspects of care into standard cancer treatment. Patients in these programs have access to a doctor, nurse, psychologist, social worker, and chaplain who are all trained in palliative oncology whereas standard oncology does not have this team. Integrative programs improve well-being while reducing futile treatments. We hypothesize that emergency department (ED) visits, inpatient admissions, intensive care unit (ICU) stays, hospital deaths, hospice referrals, and advanced care planning (ACP) are affected by these programs. Methods: A retrospective chart review analyzed patients from Parkview Regional Medical Center. Cohort A included 100 patients from a palliative oncology program. Cohort B included 100 patients who received standard oncology care. Cohorts were matched on gender, age, cancer type, and stage. Number of ED visits, ICU admissions, and inpatient stays were analyzed. Hospice referrals, hospital deaths, and ACP documents were also compared. Results: A T-test showed no difference between ED visits, ICU stays, or inpatient admissions between cohorts. A chi-square analysis also showed no difference in hospice referrals or hospital deaths. However, there were significantly more ACP documents on file for cohort A (p = 0.000132). This suggests that palliative oncology programs do not strongly affect hospital time or hospice referrals but may impact advanced care planning. Conclusion: Since the benefits of palliative oncology programs do not seem related to hospital time or hospice care, another factor must be responsible for improving patients’ quality of life. These programs emphasize family involvement and planning thus explaining the significant increase in ACP documents. Perhaps this extra support and preparedness also improves patients’ moods and well-being. Impact: Future studies should involve a larger sample size and focus on psychological aspects of these programs to determine why they benefit patient health, specifically mental health, and what improvements can be made.

Determining the Impact of COVID-19 on End-of-Life Experiences of Family Caregivers for People Living With Dementia

COVID-19 has impacted all of our lives, but the population most at risk are older adults. Family caregivers (FCGs) for people living with dementia (PLWD) face challenges in providing care, which are compounded with the introduction of COVID-19 public health policies. The purpose of this study was to examine the experiences of FCGs where the PLWD died during the COVID-19 pandemic. FCGs were invited to participate in an online survey to examine their caregiving experiences during the COVID-19 pandemic, with the option of participating in a follow-up focus group. Sixteen FCGs whose family members with dementia died during the pandemic participated in the survey. A follow-up focus group was conducted to further examine how COVID-19 policies impacted their role as a caregiver in long-term care (LTC) and affected their ability to grieve. The results of the survey and focus group suggest that a lack of role clarity and inadequate communication channels between the FCG and LTC due to COVID-19 increased the strain FCGs faced during end-of-life care. At the end of life, public policies, such as reduced or no visitation, led to feelings of inadequacy and regret. Several participants also expressed appreciation for completing Advanced Care Planning documentation prior to COVID-19. Based on these results, policymakers can help ease the increased turmoil faced by FCGs during end-of-life care in future public health emergencies by involving FCGs of PLWD in the decision-making process. The completion of Advanced Care Planning documentation can also ease the burden FCGs may experience during end-of-life care.

Predictors of positive or negative reactions to learning Alzheimer’s biomarker results

With improved detection of Alzheimer’s disease and biomarker accessibility, more adults with no or mild symptoms may learn their AD biomarker results. Yet, potential psychosocial impact of learning AD biomarkers is not well understood. In a phone survey, we assessed potential reactions after learning about a hypothetical positive AD biomarker result. Data were collected from cognitively healthy participants (n=334, mean age=64.8±7.7) enrolled in longitudinal AD studies. Exploratory factor analysis identified five latent factors following a hypothetical positive biomarker result: advanced care planning, lifestyle changes to reduce dementia risk factors, psychological distress, subjective cognitive complaints, and stigma. Using linear regression, we found that predictors of potential pessimistic reactions (distress, cognitive complaints, stigma) included higher trust in research (Distress:b:0.04, p:0.04), no dementia family history (Stigma:b:-0.30,p:0.04), poorer memory self-rating (Cognitive complaints:b:-0.19,p:0.02), and Black racial identity (Cognitive complaints:b:0.30,p:0.02, Stigma:b:0.40,p:0.003). Predictors of potential optimistic reactions (advanced care planning, lifestyle changes) included more trust in research (Planning:b:0.07,p<0.0001) and Black racial identity (Planning:b:0.38,p:0.003), as well as younger age (Lifestyle:b:-0.02,p:0.02) and belief in AD controllability (Planning:b:0.22,p:0.003, Lifestyle:b:0.23,p:0.002). Concern about developing AD was associated with increased likelihood of all potential reactions. While AD concern associates with optimistic and pessimistic potential reactions, specific factors of family history, racial identity, trust, belief in AD controllability, and memory rating differentially predict each of the potential outcomes of learning AD biomarker results. These findings may help target education efforts to prepare and reduce risk of negative reactions for cognitively healthy adults who learn their AD biomarker results.

Role of Nativity in End of Life Care Planning

Given the rapidly aging population, optimal end-of-life (EOL) consistent with individual wishes is a public health priority. Advanced Care Planning (ACP) involves Advanced Directives (AD) and establishing a Power of Attorney (POA). AD describe EOL Care preferences including options to limit treatment, withhold treatment, provide comfort care, and prolong treatments. Nativity can provide meaningful guidance in decision-making at the end of life. Data from this study came from the Health and Retirement Study, nationally representative longitudinal study of U.S. residents. The sample included 4,015 older adults, 65 and above years of age who died during study follow-up. Nativity was categorized as U.S born and Foreign born. ACP variables included presence of AD and POA, and EOLC preferences included provide comfort care, limit, withhold, or prolong treatment. Covariates included age, gender, race, marital status, education, and subjective health at baseline. Cox Proportional Hazards (Cox PH) and Weibull Models were used to identify associations between nativity and end of life care. Results: Compared to U.S born, Foreign born participants were less likely to have POA (HR: 0.75; 95% CI:0.64-0.89) in Cox PH and POA (HR: 0.63; 95 % CI:0.53-0.75) Weibull models in unadjusted models, limited treatment (HR: 1.58; 95 % CI: 1.2, 2.1), and prolong treatment (HR: 0.23; 95 % CI:0.06-0.99) and Cox PH and (HR: 0.20; 95 % CI: 0.05-0.83) in Weibull modes. Conclusion: There are differences in Advanced Care Planning by nativity. Country of origin should be considered when helping individuals plan for end-of-life care.

Dilema Etik di Rumah Sakit saat Keterbatasan Sumber Daya dalam Pandemi COVID-19

Abstract—COVID-19 has induced a global health problem with the impact to different aspects of human life. If numbers of patients are increasing beyond the healthcare capacity, the constraint of resources will stimulate ethical dilemma. In hospitals, the availability of drug, hospital beds, trained health professionals, and personal protective equipment are not enough to response patients’ needs. To face this condition, health professionals and hospitals need ethical guidance to allocate resources. This article aims to discuss the guides that are available in the international literature and to recommend Advanced Care Planning as an additional measure to manage the scarcity or resources. The communal culture or Indonesia may contribute to the ethical challenges through the ‘in-group’ and ‘out-group’ phenomenon. Keywords: COVID-19, resource allocation, ethical dilemma Abstrak—Pandemi COVID-19 telah menyebabkan masalah kesehatan global yang berdampak ke berbagai aspek kehidupan manusia. Jika angka penderita melebihi kapasitas sistem layanan kesehatan, terjadi keterbatasan sumber daya yang akan menimbulkan dilema etik. Di rumah sakit, ketersediaan obat, tempat tidur, tenaga kesehatan terlatih, alat pelindung diri tidak cukup untuk merespons kebutuhan pasien. Untuk menghadapi kondisi ini, tenaga kesehatan dan rumah sakit membutuhkan panduan etika untuk mengalokasikan sumber daya. Artikel ini bertujuan untuk mendiskusikan panduan-panduan yang ada di internasional serta mengusulkan Advanced Care Planning sebagai pendekatan tambahan dalam mengelola keterbatasan sumber daya. Budaya komunal di Indonesia dapat menambah tantangan etika di Indonesia melalui fenomena ‘dalam’ dan ‘luar’ kelompok. Kata kunci: COVID-19, alokasi sumber daya, dilema etik

Development of a predictive score for mortality at 3- and 12-month after discharge from an acute geriatric unit as a trigger for advanced care planning

Background There is a need for a mortality score that can be used to trigger advanced care planning among older patients discharged from acute geriatric units (AGUs). Objective To develop a prognostic score for 3- and 12-month mortality after discharge from an AGU, based on a comprehensive geriatric assessment, in-hospital events, and the exclusion of patients already receiving palliative care. Methods DAMAGE is a French multicentre, prospective, cohort study. The broad inclusion criteria ensured that the cohort is representative of patients treated in an AGU. The DAMAGE participants underwent a comprehensive geriatric assessment, a daily clinical check-up, and follow-up visits 3 and 12 months after discharge. Multivariable logistic regression models were used to develop a prognostic score for the derivation and validation subsets. Results 3509 patients were assessed and 3112 were included. The patient population was very older and frail or dependant, with a high proportion of deaths at 3 months (n=455, 14.8%) and at 12 months (n=1014, 33%). The score predicted an individual risk of mortality ranging from 1% to 80% at 3 months and between 5% and 93% at 12 months, with an area under the receiving operator characteristic curve in the validation cohort of 0.728 at 3 months and 0.733 at 12 months. Conclusions Our score predicted a broad range of risks of death after discharge from the AGU. Having this information at the time of hospital discharge might trigger a discussion on advanced care planning and end-of-life care with very old, frail patients.