Journal of palliative medicine
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Observational Study
Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations.
Despite palliative care implementation, most deaths still occur in hospitals. ⋯ Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.
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The number of older jail inmates in poor health is increasing rapidly. Among older adults, pain is common and leads to greater acute care use. In jail, pain management is complicated by concerns about misuse and diversion. A lack of data about the prevalence and management of pain in older jail inmates limits our ability to develop optimal palliative care strategies for this population. ⋯ High rates of pain in a rapidly growing population of older jail inmates with multimorbidity and functional impairment suggest that jails are an important site for assessing symptom burden and developing appropriate palliative care interventions.
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The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving this right, have been shown to decrease the likelihood of in-hospital death, improve the quality of care, and lower health costs in the final week of life. Despite these benefits, the rates of AD documentation are poor. ⋯ EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish whether improved documentation impacts inpatient management and costs of care.
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Missed opportunities to train medical students in generalist palliative care during core clerkships.
To improve the quality of care for dying patients, experts have called for all clinicians to be able to provide a generalist level of palliative care. Core clinical clerkships provide an opportunity to incorporate palliative care training to address the lack of required palliative care rotations at most U.S. medical schools. ⋯ At an institution without a required palliative care rotation, third-year medical students rarely or never care for patients who die during core clerkships, and when they do, their teams do not debrief or reflect on these experiences. Clinical faculty, including palliative care consultants, can address missed opportunities for palliative care training during core clerkships by augmenting and routinely debriefing students' experiences giving bad news and caring for dying patients.