Journal of palliative medicine
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As a newly recognized subspecialty, the field of hospice and palliative medicine (HPM) must transition existing pathways for board certification, fellowship standards, and fellowship accreditation to one based on the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties competency framework. The Competencies Work Group of the American Board of Hospice and Palliative Medicine, using an iterative process informed by the field, has developed a set of Initial Competency-based Outcomes for the HPM Subspecialist. These competencies will set the standard for the "competent hospice and palliative medicine subspecialist physician," guiding future HPM fellowship training and potential midcareer HPM training opportunities. Lessons learned are highlighted.
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Although palliative care services are becoming increasingly prevalent in acute care hospitals only a minority of patients who die in hospital or in the community have seen palliative care teams. There are large numbers of patients who might benefit from palliative care who are not receiving it. That said, identification of patients who are eligible for these services, and of those who would most benefit is problematic. ⋯ Institutions that are planning to develop new services, or expand their current services will require some method/tool to assess specific population needs at their site. The Hamilton Chart Audit (H-CAT) was developed at our institution to help identify potential palliative care needs of patients and their families. We report on development of the tool and use of the tool for a retrospective audit of 222 patients who died at our institution.
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Review Case Reports
Palliative sedation: when the family and consulting service see no alternative.
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Comparative Study
Length of survival of patients with cancer in hospice: a retrospective analysis of patients treated at a major cancer center versus other practice settings.
This is a retrospective study of the length of survival (LOS) in hospice of patients with cancer treated at a major cancer center compared to other treatment sites. Of 670 patients, the 185 (28%) treated at a major cancer center had unique characteristics, including higher median Palliative Performance Score (PPS) at the time of hospice enrollment (45 versus 40, p = 0.009), and longer median LOS in hospice (35 versus 21 days, p = 0.02: log rank test). ⋯ After adjusting survival for PPS with a Cox proportional hazard model, the hazard ratio for PPS remained statistically significant (95% confidence interval [CI]: 0.95-0.97] while that for the treatment site was not (95% CI: 0.73-1.04]. The performance status, and not the treatment site, was the dominant predictor of the LOS of patients with cancer in hospice.
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Terminal restlessness is a term frequently used to refer to a clinical spectrum of unsettled behaviors in the last few days of life. Because there are many similarities between the clinical pictures observed in terminal restlessness and delirium, we postulate that at times what is referred to as terminal restlessness may actually be an acute delirium sometimes caused by medication used for symptom control. It is important therefore to consider the causes for this distressing clinical entity, treat it appropriately, and ensure the treatment provided does not increase its severity. ⋯ These include opioids, antisecretory agents, anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise awareness regarding the recognition and diagnosis of delirium and to highlight the fact that delirium may be reversible in up to half of all cases. Good management of delirium has the potential to significantly improve patient care at the end of life.