Journal of palliative medicine
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Objectives: To identify patient perceptions of how and when palliative care (PC) could complement usual heart failure (HF) management. Background: Despite guidelines calling for the integration of PC into the management of HF, PC services remain underutilized by this population. Patient preferences regarding delivery of and triggers for PC are unknown. ⋯ Triggers for specialist PC focused on late-stage manifestations of disease such as loss of independence and absence of disease-directed therapies. Conclusions: Patients with HF demonstrated variable conceptions of PC and its relevance to their disease management. Although preferences for delivery model were based on a variety of logistical and relational factors, triggers for initiation remained focused on late-stage disease, suggesting that patients with HF may misconceive PC is an option of last resort.
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Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). ⋯ Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.
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Context: Increasing emphasis on patient-centered care has led to highlighted importance of shared decision making, which better aligns medical decisions with patient care preferences. Effective shared decision making in metastatic breast cancer (MBC) treatment requires prognostic understanding, without which patients may receive treatment inconsistent with personal preferences. Objectives: To assess MBC patient and provider perspectives on the role of prognostic information in treatment decision making. ⋯ Five emergent themes were identified. (1) Most patients wanted prognostic information but differed in when they wanted to have this conversation, (2) Emotional distress and discomfort was a critical reason for not discussing prognosis, (3) Religious beliefs shaped preferences for prognostic information, (4) Health care professionals differed on prognostic information delivery timing, and (5) Providers acknowledged that an individualized approach taking into account patient values and preferences would be beneficial. Conclusion: Most MBC patients wanted prognostic information, yet varied in when they wanted this information. Understanding why patients want limited or unrestricted prognostic information can inform oncologists' efforts toward shared decision making.
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Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advance care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advance directives (ADs). Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population. Design: A single trauma center's registry was retrospectively reviewed. ⋯ Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case-control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges. Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.
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Background: Immune checkpoint inhibitors (ICIs) have revolutionized treatment for many patients with advanced cancer. Little is known about ICI use near the end of life. Objective: To describe ICI use near the end of life. Design: Retrospective study of patients who received ICIs and died. Setting/Subjects: Patients treated with ICIs who died between August 2014 and December 2018 (N = 441) at the University of Iowa. Measurements: Comparisons were made between patients who received ICIs ≤30 days versus patients who received ICIs >30 days before death. ⋯ They also had higher mean Eastern Cooperative Oncology Group (ECOG) scores, more patients with ECOG ≥3, higher rates of dying in the hospital, and lower hospice enrollment. Patients treated with ICIs in the last 90 days of life received fewer doses, more often ≤3 total doses, had a higher mean ECOG score, more patients with ECOG ≥3, and lower hospice enrollment. $7.1 million USD was spent on ICI medications in the last 90 days of life. Conclusion: ICI use near the end of life is associated with poor performance status, lower hospice enrollment, dying in the hospital, financial toxicity, and minimal clinical benefit.