What components of the physical examination (PE) are valuable when providing comfort-based care for an imminently dying patients? While patient factors must be individualized, this Fast Fact assimilates the sparse published evidence along with anecdotal experience to offer clinical pearls on how to tailor the PE.
OBJECTIVE: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care.
METHODS: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated.
RESULTS: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues.
CONCLUSIONS: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.
Clinicians have been encouraged to utilize the surprise question (SQ) - "Would I be surprised if this patient died within 12 months?" - to identify patients at high one-year mortality risk. When clinicians answer "No - I would NOT be surprised if this patient died within 12 months," the SQ may help clinicians identify patients with unmet palliative care needs who could benefit from advance care planning and/or a palliative care referral. This Fast Fact reviews the clinical utility of the SQ.
Status epilepticus is a common and under-recognized cause of unconsciousness among hospitalized patients. It can clinically mimic delirium and other causes of acute mental status change, especially when clinically relevant seizure activity is not appreciated on physical examination. While the successful treatment of status epilepticus may require anesthetic dosing of antiepileptics such as barbiturates, these seemingly drastic therapeutic measures are justified when goals of care are life prolonging as they may allow a patient to regain consciousness and meaningfully interact with loved ones. However, medical burden from electroencephalogram (EEG) monitoring and other care associated with its diagnosis and treatment can contribute to distress for patients who may be dying from a comorbid illness. Furthermore, when goals of care transition to comfort, care challenges can result regarding the ongoing management of barbiturates or other sedatives, previously prescribed to treat the status epilepticus. In this case study, the lack of clinically significant seizure activity led us to conclude that the discontinuation of a barbiturate infusion and the EEG monitoring was the clinically appropriate approach for a dying patient with comfort goals of care and nonconvulsive status epilepticus.
Background Diuretics are a mainstray of treating symptomatic volume overload in heart failure (HF), including at the end of life. For some patients, bowel edema from HF-related congestion can diminish the absorption and effectiveness of oral diuretics. Intravenous diuretics, however, are difficult to administer in an outpatient or hospice setting, which likely contributes to the frequent emergency department visits and hospitalizations in HF, even near the end of life. In this context, subcutaneous (SC) furosemide can be helpful. This Fast Fact reviews its use.
BACKGROUND: Fast Facts Mobile (FFM) was created to be a convenient way for clinicians to access the Fast Facts and Concepts database of palliative care articles on a smartphone or tablet device. We analyzed usage patterns of FFM through an integrated analytics platform on the mobile versions of the FFM application.
OBJECTIVE: The primary objective of this study was to evaluate the usage data from FFM as a way to better understand user behavior for FFM as a palliative care educational tool.
DESIGN: This is an exploratory, retrospective analysis of de-identified analytics data collected through the iOS and Android versions of FFM captured from November 2015 to November 2016.
MEASUREMENTS: FFM App download statistics from November 1, 2015, to November 1, 2016, were accessed from the Apple and Google development websites. Further FFM session data were obtained from the analytics platform built into FFM.
RESULTS: FFM was downloaded 9409 times over the year with 201,383 articles accessed. The most searched-for terms in FFM include the following: nausea, methadone, and delirium. We compared frequent users of FFM to infrequent users of FFM and found that 13% of all users comprise 66% of all activity in the application.
CONCLUSIONS: Demand for useful and scalable tools for both primary palliative care and specialty palliative care will likely continue to grow. Understanding the usage patterns for FFM has the potential to inform the development of future versions of Fast Facts. Further studies of mobile palliative care educational tools will be needed to further define the impact of these educational tools.