A National Survey of Palliative Care Team Compositions

Purpose: It is unclear how well palliative care teams are staffed at US cancer centers. Our primary objective was to compare the composition of palliative care teams between National Cancer Institute (NCI)-designated cancer centers and non-NCI-designated cancer centers in 2018. We also assessed changes in team composition between 2009 and 2018. Methods: This national survey examined the team composition in palliative care programs at all 61 NCI-designated cancer centers and in a random sample of 60 of 1252 non-NCI-designated cancer centers in 2018. Responses were compared to those from our 2009 survey. The primary outcome was the presence of an interprofessional team defined as a palliative care physician, nurse, and psychosocial member. Secondary outcomes were the size and number of individual disciplines. Results: In 2018, 52/61 (85%) of NCI-designated and 27/38 (71%) non-NCI-designated cancer centers in the primary outcome comparison responded to the survey. NCI-designated cancer centers were more likely to have interprofessional teams than non-NCI-designated cancer centers (92% vs 67%; P = .009). Non-NCI-designated cancer centers were more likely to have nurse-led teams (14.8% vs 0.0%; P = .01). The median number of disciplines did not differ between groups (NCI, 6.0; non-NCI, 5.0; P = .08). Between 2009 and 2018, NCI-designated and non-NCI-designated cancer centers saw increased proportions of centers with interprofessional teams (NCI, 64.9% vs 92.0%, P < .001; non-NCI, 40.0% vs 66.7%; P = .047). Conclusion: NCI-designated cancer centers were more likely to report having an interprofessional palliative care team than non-NCI-designated cancer centers. Growth has been limited over the past decade, particularly at non-NCI-designated cancer centers.

The Virulence of Grief in the Pandemic: Bereavement Overload During COVID

The COVID-19 pandemic brought about bereavement overload as a risk factor for complicated grief. Bereavement overload (BO) describes individuals’ reactions to losses transpiring in a quick succession, without the time and opportunity for coping [9]. It can occur during catastrophic events and impact everyone experiencing the loss. With the high death toll from COVID-19, many people have lost multiple loved ones followed by an abbreviated grieving process due to the nature of the pandemic. This can have psychosocial impact on survivors for years. One of the evolving roles of Palliative Care within and after the pandemic should be to recognize those suffering from BO. Obtaining loss histories may identify those at risk of pathologic grief to provide preventive bereavement care. We present three cases encountered in our health system during the COVID-19 pandemic amongst a family member, a patient, and a healthcare provider. In each case the Palliative Care Team worked closely with these individuals to identify COVID-associated BO and helped them reconcile their unresolved grief to be able to move forward. These cases reflect only a fraction of those who experienced loss during the pandemic, but they illustrate how grief can be complicated by the pandemic for everyone involved. Palliative Care will have a crucial role moving forward, in treating the pandemic of complicated grief within the pandemic to adapt to the needs of all survivors, as we realize the effects of COVID will last long after its virulence has waned.

Effects of the COVID-19 Pandemic on Place in End-of-Life Care: Insights From a Homeless Mobile Palliative Care Team

The effects of the COVID-19 pandemic on both those experiencing homelessness (Tsai & Wilson, 2020) and those with life-limiting illnesses (Abbott et al., 2020) is of great public health concern. This presentation details the findings from an organizational case study (Yin, 2014) aimed at investigating COVID-related changes to the service environments in which unhoused palliative care patients receive care. Through ethnographic field observation (Phillippi & Lauderdale, 2017) and interviews with a homeless palliative care team and their community partners (Turner, 2005), findings included 1) decreased staff capacity due to de-congregated care; 2) efforts to extend care in community settings due to relocation barriers; 3) conflict between reducing viral risk and honoring unique population needs; and 4) provider perceptions of COVID-19 as an “equalizer.” Findings illustrate the impact of emergency response within housing and healthcare systems on unhoused patients’ care and offer potential pathways to quality end-of-life care for homeless populations.

Investigating Barriers and Facilitators to Congruence in Place of Care Among Unhoused Palliative Care Patients

An important quality marker for end-of-life services is congruence with patient’s preferred place of care, but this congruence in place of care is less likely for those facing structural inequalities (Grunier et al., 2007). As homelessness among older adults in the United States grows (Culhane et al., 2013), the urgency in understanding place of care in palliative care with unhoused patients grows. This presentation illustrates results from an organizational case study (Yin, 2014) of a novel homeless palliative care team and focuses on a qualitative content analysis of charts of patients over 50 receiving care both before and during the COVID-19 pandemic (n=27). Findings highlight (1) the interplay between environmental factors, psychosocial resources and constraints, and medical acuity in determining where care can take place, (2) facilitators for care in marginal settings such as emergency shelters and encampments, and (3) where opportunities for more equitable age-friendly healthcare system interventions exist.

Dermatomyositis Identified During Palliative Care Management for Chemotherapy-Associated Pain: A Case Report

Introduction: Skin disorders and neuropathy often occur as side effects of chemotherapy. We encountered a patient who was treated for drug-induced skin symptoms, but the symptoms did not improve, and he was eventually diagnosed as having dermatomyositis. Case presentation: A 71-year-old man underwent chemotherapy with regorafenib in February 2020 for the postoperative recurrence of sigmoid colon cancer, but treatment was discontinued after about 2 months owing to the appearance of skin symptoms, which were thought to be side effects of regorafenib. Subsequently, his symptoms further worsened, and he was hospitalized 3 weeks after the appearance of the initial skin symptoms, and a palliative care team was asked to relieve his back pain caused by the drug-induced skin symptoms. Erythema was widely observed on the lower back and limbs, and he experienced needle stick-like pain. Furthermore, the patient demonstrated difficulty in lifting both upper limbs. As acetaminophen was effective for his pain, the dose was slowly increased with careful observation. The cause of the patient’s muscle weakness was unclear, and after careful discussion of the possible causes among specialists in dermatology, neurology, and rheumatoid arthritis, a diagnosis of dermatomyositis associated with the malignant tumor was made about 10 days after his admission. The patient’s symptoms gradually improved with steroid pulse treatment (methylprednisolone 1 g/day for 3 days) followed by high-dose gamma globulin treatment (2.5 g/day for 5 days), and the patient was discharged 48 days after admission. Discussion: Because this patient was referred to a palliative care team for the purpose of relieving pain caused by skin symptoms associated with chemotherapy, a crucial point is the symptoms were treated as side effects of the chemotherapy from the beginning. As neuropathy can occur as a result of chemotherapy, the pain and muscle weakness could be explained at the time; however, the symptoms continued to worsen even after the chemotherapy was stopped. Because the symptoms were not typical of polymyositis/dermatomyositis, diagnosis of the patient was delayed, even though he was treated in each specialized department. Our present case indicates that paraneoplastic syndrome should always be kept in mind when treating cancer patients.

The Truth, the Whole Truth, and Nothing but the Truth: Therapeutic Privilege

The term therapeutic privilege is unfamiliar in the medical field and often sparks questions and discomfort about its ethical implications. Therapeutic privilege refers to the act of withholding of information by a clinician, with the underlying notion that the disclosure of this information would inflict harm or suffering upon the patient1. This is a case of a 56-year-old woman who presented to our facility in critical condition: sepsis with acute respiratory failure requiring intubation and mechanical ventilation. Prior to her admission, her husband had been admitted at our facility and was being cared for in the intensive care unit. On the same day that our patient was extubated, her husband had died. The palliative care team was consulted to assist with disclosing this information to the patient in light of her emotional fragility, her anxiety and concerns for her ability to receive such news given her own active illnesses.

Der patientenzentrierte Notfallplan – Erfahrungen aus der Praxis

Zusammenfassung. Der Wunsch vieler Menschen in der Schweiz ist es, zu Hause sterben zu können. Der vorliegende Praxisbericht zeigt beispielhaft, wie die Zusammenarbeit von Hausärztinnen und Hausärzten und einem spezialisierten Palliative- Care-Team sowie die Anwendung eines individuell auf das Therapieziel und die Grundkrankheit der Patientin/des Patienten adaptierten Notfallplans die Umsetzung dieses Wunsches unterstützen können. Eine gute Koordination der gesundheitlichen Vorausplanung (Advance Care Planning) durch einen individualisierten, patientenzentrierten Notfallplan sowie die gemeinsame Umsetzung der Betreuung durch das interdisziplinäre, multiprofessionelle Behandlungsteam und die Organisation eines gutes Betreuungsnetzwerks sind essenzielle Bestandteile, damit ungewollte Notfallhospitalisationen am Lebensende vermieden werden können.

Identifying the Needs Based on the Patients’ Performance Status for Palliative Care Team: An Observational Study

Objectives: The study aim was to determine the association between patient performance status (PS) and the contents of a palliative care team (PCT) intervention. Identifying intervention requirements for differing PS may help to provide appropriate palliative care in under-resourced facilities. Materials and Methods: We collected data from medical records of inpatients (n = 496) admitted to PCT services at a centre for palliative care at Kindai University Hospital, Japan, from April 2017 to March 2019. We analysed the content of PCT activities according to each PS using Pearson’s Chi-square test. Results: The following PCT activities were provided in full regardless of PS: Gastrointestinal symptoms, depression, medical staff support, food and nutrition support and oral care. The following PCT responses were associated with PS: Pain, respiratory symptoms, fatigue, insomnia, anxiety, delirium, decision-making support, family support and rehabilitation. PS3 patients tended to receive those PCT interventions associated with PS, except for anxiety and fatigue. PS4 patients received PCT interventions for respiratory symptoms, delirium and family support. Patients with good PS (0–1) tended to receive PCT interventions for anxiety. Conclusion: This study demonstrated that there were different needs for different PS. The results may allow for efficient interventions even in facilities with limited resources.

The Role of Perinatal Palliative Care in Fetal Neurology

Many serious or life-threatening neurologic conditions are first diagnosed during the fetal period, often following a routine prenatal ultrasound or sonographic evaluation after an abnormal aneuploidy screen. Such conditions represent a worrisome or unexpected finding for expectant parents, making the perinatal period a critical time point to engage and empower families encountering complex clinical neurologic clinical scenarios. The prenatal identification of structural abnormalities of the brain or spinal cord, radiographic signs of hemorrhage or ischemic injury, or evidence of genetic or metabolic conditions should all prompt involvement of a fetal palliative care team to work alongside obstetric and neonatal providers. The inherent prognostic uncertainty is challenging for prenatally diagnosed neurologic conditions, which have a wide range of severity and difficult to predict short and long-term outcomes. While many of these conditions will lead to the birth of an infant with neurodevelopmental challenges, few will result in in utero demise. Palliative care beginning in the perinatal period provides an additional layer of support for families navigating complex decision making during their pregnancy and provides continuity of care into the newborn period. Palliative care principles can help guide discussions around genetic and other diagnostic testing, fetal surgery, and birth planning. A multidisciplinary team can help guide and support families through pre- and postnatal decision making and through bereavement care in the setting of fetal or neonatal death. Early involvement of a tailored palliative care team can provide a more holistic approach to the counseling process, facilitate planning and conversations, and ensure that the family’s goals and wishes are acknowledged throughout the infant’s care trajectory.