Citations

Background Native American (NA) patients experience persistent inequities in advance care planning (ACP) and often present to tertiary centers with critical illness; culturally respectful serious-illness communication is therefore essential in emergency and intensive care settings. Intervention We developed and implemented a nursing-led, multidisciplinary educational initiative at a large academic medical center serving patients from >50 tribal nations. Informed by a literature review, local practice needs, and expert input from a Native American Patient Experience Ambassador, we created (1) an “Honoring Your Choices” (HYC) communication card with culturally sensitive prompts for serious illness conversations and (2) a quick reference guide (QRG) outlining key cultural considerations and unit-specific resources. Tools were disseminated to seven intensive care units and the emergency department through nurse leader engagement, unit rounding, and staff education, and the initiative was presented at departmental Grand Rounds/didactics with pre/post surveys to assess impact. Results Twenty-seven pre-session and twenty-four post-session surveys were collected from clinicians and trainees. Prior to the session, >80% of respondents reported being not or only slightly confident discussing end-of-life issues with NA patients/families; post-session surveys demonstrated increased self-reported confidence in recognizing when cultural beliefs may influence care and in conducting end-of-life discussions. Conclusions This initiative demonstrates how culturally congruent approaches to serious illness conversations may support more meaningful engagement with NA patients and families. Our experience suggests that developing and evaluating a brief, point-of-care communication tool like Honoring Your Choices may be accomplished with existing interdisciplinary partnerships, offering a practical model that other institutions can readily mirror.

Context: Early palliative care can improve end-of-life outcomes, but referrals to palliative care specialists can be delayed in the primary care setting. Objective: This pilot study assessed the effect of a machine-learning algorithm on time to palliative care in a primary care population. Methods: Patients (aged ≥18 years) were eligible if they were empaneled with a primary care provider (PCP) from July 20, 2020, through May 30, 2021. The algorithm evaluated their health records and presented patients who were predicted to have the greatest need for palliative care. Records were then reviewed by palliative care specialists, and patients were randomized in a stepped-wedge fashion to have a referral notification sent to their PCPs if unmet palliative care needs were verified. Time-to-event outcomes were evaluated with Poisson regression models. Results: Of the 127,080 patients evaluated, 934 had their health records presented for review. Some patients were repeatedly presented by the algorithm (total presentations: 1592). In the intervention arm, PCPs were prompted to order a palliative care consultation for 142 patients. The time to 0.1% of the population receiving a palliative care consultation was 60.9 days for the intervention arm versus 71.8 days for the control arm (probability of a shorter time with the intervention, 0.88). Conclusion: A machine-learning algorithm to identify palliative care needs was successfully integrated into a primary care practice. More work is needed to improve the workflow.

Hospice and palliative medicine (HPM) simulation training primarily focuses on communication skills, rather than symptom management. Simulation can be an effective educational tool in high stakes clinical settings and provides a safe environment to improve skills in crisis management. HPM providers are often called to manage refractory symptoms in emotionally charged situations, especially at end-of-life care. These scenarios may present infrequently during their 1-year fellowship training. We describe a novel two-part simulation series ‘End of Life Symptom Management: Emergencies in Palliative Medicine’ that we have developed for our interdisciplinary HPM Fellowship. Our simulation series is conducted at our institution’s simulation centre and includes scenarios of (1) refractory pain, (2) palliative sedation, (3) initiation of buprenorphine-naloxone for cancer-associated pain in a patient with opioid use disorder (OUD), (4) acute pain crisis in a hospice patient with OUD on buprenorphine-naloxone, (5) terminal delirium, (6) compassionate extubation/respiratory distress, (7) status epilepticus and (8) terminal haemorrhage. Pre and postsession data collected from our HPM fellows reflect an increase in confidence levels after participating in the sessions. This simulation curriculum has allowed our fellows the opportunity to encounter and navigate these scenarios in a safe and controlled learning environment before encountering them in practice.

Purpose There is emerging evidence that music therapy (MT) is an effective tool within palliative care to manage patients’ complex needs. This performance improvement project aimed to assess palliative care staff members’ attitudes toward the current utilization of MT within the institution’s hospital-based interdisciplinary practices. Methods Eighty-four staff members practicing within hospital-based palliative care teams were invited to complete a voluntary anonymous mixed methods survey about their impressions of current MT integration. Survey questions inquired about reasons for MT referral, most common pertinent symptoms, perceived benefit to patients, future suggestions for growth, unexpected experiences, and perceived personal benefit to staff. Major Findings Fifty-one staff members (61%) responded. Top reasons for MT referral were psychosocial support, pain and symptom management, and coping. The most common symptom-focused indications were anxiety, mood, and existential distress. A variety of factors influenced decisions to refer for MT. Most felt that at least half of their patients could benefit from MT, and nearly all rated MT as “extremely” or “very” effective for improving patients’ quality of life. Suggestions for potential growth for MT in palliative care in the future centered on themes of greater availability, increased variety and collaboration, research opportunities, and staff members’ desire to receive more exposure to MT. Conclusions In this single-institution performance improvement project, staff attitudes were highly favorable toward MT for palliative care patients. MT is utilized for a variety of reasons, can be highly effective for improving patients’ quality of life, and may also be of direct benefit to staff.

Background: Collaborative methods are necessary to meet patient palliative care (PC) needs because of the inadequate supply of PC specialists. Objective: This study aimed to conduct a needs assessment and determine primary care, emergency, and hospital physicians’ general attitudes about primary PCs, confidence in managing common PC scenarios, and preferences for interaction with specialty PCs. Design: A sequential mixed-methods study design was used, whereby individual qualitative interviews informed the content of a quantitative survey. Semistructured telephone interviews were conducted by a member of the study team with expertise in qualitative research methods. Setting/Subjects: The quantitative survey, delivered to primary care, emergency, and hospital physicians across four distinct geographic locations of a large health system, solicited impressions on common clinical PC scenarios that might pose challenges. Measurements: Survey data included demographic information, clinician confidence levels, preferences for support in managing PC scenarios, and likelihood to refer to PC. Results: The quantitative survey was completed by 126 physicians (response rate, 13.9%). Overall mean (standard deviation) confidence levels were lowest for a scenario about handling pain (5.57 [2.35] out of 10) and highest for goals-of-care conversations with the patient (7.80 [2.02]). Spearman correlations between mean confidence and likelihood to refer to PC demonstrated weak to moderate inverse correlations. Respondents with previous training in PC had higher mean confidence in managing symptoms and goals-of-care conversations. Conclusions: Continuing efforts are needed to help improve physicians’ confidence in primary PC skills and develop innovative methods to provide collaborative support of specialty PCs across various specialties and PC needs.

Objectives: Recent evidence suggests that music therapy, a holistic method of care, potentially is beneficial for symptom management. This quality improvement project aimed to evaluate the effect of music therapy on symptom management and coping skills of patients receiving palliative care and to measure patient satisfaction with the therapy. A secondary aim was to evaluate staff perception of patient outcomes of music therapy services. Methods: Palliative care clinicians attended a 30-minute education session on music therapy before the project was initiated. Study participants were patients and their families who were cared for by the inpatient palliative care consulting service at Mayo Clinic (Rochester, Minnesota) from June 1 through December 31, 2016. Patients were eligible if they required ongoing management of pain and anxiety or needed adaptive coping strategies. Patients and families were asked to complete a survey after each music therapy session. Staff were asked to complete a survey after completion of the project. Results: Music therapy was provided to 57 patients and 53 family members. Patient surveys indicated a decrease in anxiety and pain. All patients reported that music therapy facilitated stress relief, relaxation, pain relief, spiritual support, emotional support, and a general feeling of wellness. All participants recommended music therapy services for others. Palliative care clinicians reported that music therapy added value as a holistic service. Conclusions: In this quality improvement project, music therapy positively affected multiple domains of well-being for patients receiving palliative care.