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The addition of a do-not-operate (DNO) section to current medical orders for life-sustaining treatment (MOLST) and physician orders for life-sustaining treatment (POLST) medical order forms would more completely document patients' wishes for invasive interventions at the end of life. We propose a modification of the MOLST and POLST forms, in addition to hospital and electronic medical records, to
CONTEXT: Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The "surprise question" (SQ) "Would you be surprised if this patient died in the next 12 months?" is a simple tool to identify patients at risk
BACKGROUND: Growing evidence demonstrates the benefits of early, integrated palliative care (PC) for patients with advanced cancer and their caregivers. Yet, data are lacking on the communication patterns within this model of care.OBJECTIVE: The goals of this study were to describe the content of patient-clinician discussions among patients receiving PC and to compare differences in discussion con
Purpose We describe the key elements of early palliative care (PC) across the illness trajectory and examine whether visit content was associated with patient-reported outcomes and end-of-life care. Methods We performed a secondary analysis of patients with newly diagnosed advanced lung or noncolorectal GI cancer (N = 171) who were randomly assigned to receive early PC. Participants attended at le
Patients and families facing serious illness often want and need their clinicians to help guide medical decision making by offering a recommendation. Yet clinicians worry that recommendations are not compatible with shared decision making and feel reluctant to offer them. We describe an expert approach to formulating a recommendation using a shared decision-making framework. We offer three steps t
Purpose The early integration of oncology and palliative care (EIPC) improves quality of life (QOL) and mood for patients with advanced cancer. However, the mechanisms by which EIPC benefits these outcomes remain unclear. We therefore examined whether EIPC improved patients' coping strategies and if changes in coping accounted for intervention effects on QOL and depressive symptoms. Patients and M
Many patients with serious illness struggle to talk about the possibility of dying; yet basic prognostic awareness is crucial for informed decision making. In this article, we aim to help outpatient clinicians working with seriously ill patients ambivalent, uncomfortable, or fearful of further discussion about the future. We describe a dual framework that focuses on living well while acknowledging
BACKGROUND: The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient-reported quality of life (QOL) and mood, its effects on caregivers' outcomes is currently unknown.MATERIALS AND METHODS: We conducted a randomized trial of early PC integrated with oncology care versu
BACKGROUND: We aim to address palliative care workforce shortages by teaching clinicians how to provide primary palliative care through peer coaching.INTERVENTION: We offered peer coaching to internal medicine residents and hospitalists (attendings, nurse practioners, and physician assistants).MEASURES: An audit of peer coaching encounters and coachee feedback to better understand the applicabilit
Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the inte
We present a case illustrating the common problem of a surrogate decision maker who is psychologically distressed over the medical team's recommendation to withdraw life-sustaining treatment. We suggest how a do-not-escalate-treatment (DNET) order can be helpful in such situations when the usual approaches to withholding or withdrawing care are not acceptable to the surrogate. We define a DNET ord
BACKGROUND: Many physicians have difficulty with discussions about prognosis. The aims of this study were to evaluate why physicians struggle to discuss prognosis and to measure the effect of a 90-minute communication workshop on self-reported skill.MEASURES: An evaluation study was used with three measurement points: before the 90-minute communication workshop (e-mail survey); immediately after t
BACKGROUND: Early palliative care provides better quality of life, increased prognostic awareness, and even improved survival for patients with advanced cancer but how the integrated care model achieves these outcomes has not been completely explained.METHODS: To better understand the clinical approach to early outpatient care from the clinicians' perspective, we conducted focus groups with the pa
Continuity outpatient palliative care practice is characterized by long relationships between patients, families, and palliative care clinicians and by periods of relative stability when the disease and resultant symptoms are less active. Compared to inpatient palliative care, outpatient practice requires a greater focus on encouraging healthy coping and on helping patients to live well with serio
Early, integrated palliative care delivered in the ambulatory setting has been associated with improved quality of life, lower rates of depression, and even prolonged survival. We outline an expert practice that provides a step-wise approach to cultivating prognostic awareness in patients cared for by a palliative care clinician early in the course of the patient's disease. This approach can be us
Called in after discussions about prognosis between referring clinicians and patients, palliative care consultants sometimes find that the patient does not seem to understand what the referring clinician believes he or she explained. However, holding a more explicit discussion about prognosis may compromise the palliative care clinician's rapport with both the patient and the referring clinician.
BACKGROUND: Although palliative care consultation is recommended early in the course of oncology treatment, little evidence exists to guide the nature of this intervention. We describe a clinical practice of early palliative care consultation that improved quality of life, mood, and survival in a randomized clinical trial.METHODS: As part of a randomized trial of early palliative care versus stand
Subcutaneous lymphatic drainage has been reported to be an effective treatment for severe refractory lymphedema in patients with lymphatic accumulation because of obstructive cancer. We review published techniques for lymphatic drainage and describe two cases where these techniques were modified with good results.
