An Unusual Presentation of Catatonia-Like Behavior: Differentiating Malingering from Catatonia

Malingering involves the intentional production of physical or psychological behaviors due to motivation from external incentives, posing unique challenges to healthcare. Although malingering as an entity has been well studied, the current literature does not explore the intentional production of catatonia-like behavior or how to differentiate malingering from catatonia. Here, we describe a 45-year-old female who was admitted to an acute psychiatric hospital with a complex presentation of catatonia-like signs that was ultimately thought to be volitional behavior, resulting in a diagnosis of malingering. We highlight the important factors considered in her presentation, the differences between her behaviors and true catatonia, and other important differential diagnoses to consider. Although a diagnosis of malingering is difficult to make, we underscore the importance of reaching this conclusion in order to avoid unnecessary and potentially harmful medical interventions. We stress the importance of shifting focus from medical management to more appropriate patient goals such as providing social services and treatment of other underlying psychiatric illnesses.

Documentation of goals of care discussions: Lessons from the Improving Goal Concordant Care Collaborative.

166 Background: Patients with advanced cancer do not reliably receive care consistent with their goals and values. Goal-concordant care requires effective, efficient and timely communications between patients and their providers, as well as systems to capture patient goals and ensure future accessibility. Currently, electronic health records (EHR) in most oncology settings do not adequately support structured documentation that is most relevant to goals of cancer care. Methods: The Alliance of Dedicated Cancer Centers (ADCC) initiated the Improving Goal Concordant Care (IGCC) Initiative in 2019. ADCC members are 10 U.S. freestanding, academic cancer hospitals, which are also the IGCC participants. In 2019 and 2020, we convened palliative care and oncology experts in the IGCC’s planning phase, via a series of structured consensus building sessions. We employed modified Delphi processes - including literature review, brainstorming, voting, and refinement - in conceptualization four core components considered essential to improving goal concordant care for cancer patients. One of these core components is EHR documentation of GOC discussions; an additional EHR workgroup created detailed recommendations. The three-year IGCC implementation phase launched in September 2020. Results: We achieved consensus on minimum desired fields for GOC documentation: intent of the current treatment, physician's estimated prognosis, prognosis disclosed/discussed with patient, patient prognostic awareness, patient goals, recommendations. Further, GOC documentation must be discrete and structured whenever possible to ease entry and facilitate retrieval/reporting. As GOC discussions evolve over time, documentation may be iterated over multiple encounters. GOC documentation is distinct from, but may rely on, advance directives or other ACP documentation, such as code status, POLST/MOLST, and healthcare agents. At IGCC collaborative launch, none of the 10 cancer hospitals had EHRs that were fully compliant. Progress toward development, training, and use of structured GOC documentation is ongoing. Conclusions: Establishing feasible and useful expectations for electronic documentation of GOC discussions by oncologists presented unique challenges for the IGCC. Ongoing and planned work in this area includes: Facilitating collaborative learning and promoting sharing of best practices; Measuring the presence of GOC documentation among priority patients, as well as other measures including patient and family reported outcomes; Assessing quality of the GOC documentation; Ongoing engagement of patient and family advisors, including regarding patient access to records containing GOC documentation; Potential application of natural language processing/artificial intelligence in prompting GOC documentation and facilitating retrieval.

Clinical Outcomes Following Re-Operations for Intracranial Meningioma

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1–4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8–366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9–41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1–86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

Rationale and proposed framework for shared decision making in cardio-oncology

Physicians have a duty to present diagnostic and therapeutic choices with rational guidance that respects patient values and realizes patient goals. In cardio-oncology, we commonly encounter patients who understandably feel overwhelmed or feel that they have no favorable options, particularly in the context of advanced malignancy. Accordingly, a longitudinal multidisciplinary commitment to shared decision making (SDM) ensures that physicians and patients actively participate in this process to promote the best possible outcomes from the patient perspective. We propose a practical framework for approaching these difficult decisions in cardio-oncology drawing upon our experience in clinical practice.

Using Natural Language Processing to Classify Serious Illness Communication with Oncology Patients

One core measure of healthcare quality set forth by the Institute of Medicine is whether care decisions match patient goals. High-quality "serious illness communication" about patient goals and prognosis is required to support patient-centered decision-making, however current methods are not sensitive enough to measure the quality of this communication or determine whether care delivered matches patient priorities. Natural language processing offers an efficient method for identification and evaluation of documented serious illness communication, which could serve as the basis for future quality metrics in oncology and other forms of serious illness. In this study, we trained NLP algorithms to identify and characterize serious illness communication with oncology patients.

Development of Learning Objectives for a Medical Assistance in Dying Curriculum for Family Medicine Residency

Background Medical assistance in dying (MAID) became legal across Canada when Bill C-14 was passed in 2016. Currently, little is known about the most effective strategies for providing MAID education, and the importance of integrating MAID into existing curricula. In this study, a set of learning objectives (LOs) was developed to inform a foundational MAID curriculum in Canadian Family Medicine (FM) residency training programs. Methods Mixed-methods were used to develop LOs based on a previously-published needs assessment from a large, four-site family medicine residency program in southeastern Ontario. Draft LOs were evaluated and modified using a modified Delphi process and focus group which included faculty and resident leaders. LOs were mapped to the existing family medicine residency curriculum, as well as the College of Family Physicians of Canada’s Priority Topics and CanMEDS-Family Medicine roles. Results Nine LOs were developed to provide a foundational education regarding MAID. While all LOs could be mapped to the Domains of Clinical Care with the departmental curriculum, they mapped inconsistently to departmental Entrustable Professional Activities, the Priority Topics, and CanMEDS-FM roles. LOs focused on patient education and identification of patient goals were most readily mapped to existing curricular framework, while LOs with MAID-exclusive content revealed gaps in the current curriculum. Conclusions The developed LOs provide a guide to ensure family medicine residents obtain generalist-level knowledge to counsel their patients about MAID. These LOs can serve as a model for developing learning objectives for both family medicine and specialist residency programs in Canada, as well as globally in countries where assisted dying is legal.

Impact of a Longitudinal Intervention to Improve Care Coordination between a Hospital and a Hospice: A Quality Improvement Project

Objectives: When patients with advanced cancer transition from systemic cancer treatments at MNJ Institute of Oncology to palliative and end-of-life care at a separate stand-alone non-governmental organisation-run hospice facility, there is insufficient transfer of health information, including details of cancer diagnosis and staging, past treatments, imaging reports and goals for future care. Without this information, the hospice care team is not adequately prepared to receive and deliver high-quality palliative care for these patients. This project aims to improve the care coordination between the hospital and hospice. Materials and Methods: The measures used are the self-reported confidence score on a scale of 0 to 10 related to knowledge about plan of care among staff who receives patients at hospice at baseline and during and after interventions. Interventions included recognizing the workplace culture and promoting ownership of the tasks, enhancing communication by creating user-friendly transfer forms and on-going assessment of the process. Results: Improvement in the care coordination in terms of communication of patient goals of care, from hospital to hospice. Conclusion: QI project and the steps involved helped the team to work towards solutions objectively. Seemingly excellent ideas may not be the most impactful and data collection demonstrates this and helps identify the most successful interventions.

It may help you to know. . .": The early phase qualitative development of a rheumatoid arthritis goal elicitation tool

Objective Treatment guidelines for rheumatoid arthritis (RA) include a patient-centered approach and shared decision making which includes a discussion of patient goals. We describe the iterative early development of a structured goal elicitation tool to facilitate goal communication for persons with RA and their clinicians. Methods Tool development occurred in three phases: 1) clinician feedback on the initial prototype during a communication training session; 2) semi-structured interviews with RA patients; and 3) community stakeholder feedback on elements of the goal elicitation tool in a group setting and electronically. Feedback was dynamically incorporated into the tool. Results Clinicians (n=15) and patients (n=10) provided feedback on the tool prototypes. Clinicians preferred a shorter tool de-emphasizing goals outside of their perceived treatment domain or available resources, highlighted the benefits of the tool to facilitate conversation but raised concern regarding current constraints of the clinic visit. Patients endorsed the utility of such a tool to support agenda setting and prepare for a visit. Clinicians, patients, and community stakeholders reported the tool was useful but identified barriers to implementation that the tool could itself resolve. Conclusion A goal elicitation tool for persons with RA and their clinicians was iteratively developed with feedback from multiple stakeholders. The tool can provide a structured way to communicate patient goals within a clinic visit and help overcome reported barriers, such as time constraints. Incorporating a structured communication tool to enhance goal communication and foster shared decision making may lead to improved outcomes and higher quality care in RA.

Management of urinary incontinence in women with overactive bladder in urologist daily practice

Urinary incontinence urinary incontinence is common among women and contributes to decreased quality of life. Several effective treatment options are available for the most common types of urinary incontinence (stress, urge, and mixed), including lifestyle modification and behavioral technique, drug therapy, and minimally invasive procedures. Most women improve with treatment, and urinary incontinence is not an inevitable part of aging. To maximize the opportunity for successful treatment, it is essential to align the therapeutic approach with patient goals and expectations for care, including an assessment of patient-driven priorities regarding potential adverse effects, costs, and expected benefit of different treatment approaches. There are many unique challenges in treating an overactive bladder in older women, such as functional and cognitive impairment, multimorbidity, polypharmacy, and estrogen deficiency, all of which contribute to treating symptoms in older women. This review highlights the current understanding of age-related changes in bladder function and proposes specific clinical considerations for overactive bladder management specific to older women.