Journal of general internal medicine
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The aim of this update is to summarize scientifically rigorous articles published in 2010 that serve to advance the field of palliative medicine and have an impact on clinical practice. ⋯ We first identified 126 articles with potential relevance. We presented 20 at the annual SGIM update session, and discuss 11 in this paper.
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Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients' preferences for additional treatment. ⋯ Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.
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The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. ⋯ A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.
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Randomized Controlled Trial
Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial.
Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system. ⋯ A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.
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Specialty referral patterns can affect health care costs as well as clinical outcomes. For a given clinical problem, referring physicians usually have a choice of several physicians to whom they can refer. Once the decision to refer is made, the choice of individual physician may have important downstream effects. ⋯ Specialists frequently initiate referrals, bypassing PCPs. In choosing specific physicians to refer to, PCPs are more often concerned with between-physician communication and patient access. Modifying referral practices among doctors may need to account for such patterns of behavior.