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One Rotation at a Time: Strengthening the Bond Between Anesthesia and Palliative Medicine (S763)
456
Poster Abstracts
Cancer Institute, Cleveland, OH. Lisa Rybicki Cleveland Clinic Foundation, Cleveland, OH. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Recall the three important patient characteristics that influence cancer symptom profile. 2. Learn how to interpret results of cancer treatment and symptom control studies by using the context of patient characteristics Background. To date, the influence of patient demographics on cancer symptom profile has only been studied individually. Research Objectives. To explore the influence of the combined interaction of age, gender, and performance status (PS) on the prevalence of eight cancer symptoms. Method. 38 symptoms were assessed in 1000 consecutive advanced cancer patients. The association of three demographic factors with each symptom was examined using logistic regression analysis. The prevalence of eight symptoms was associated with more than one of the three. Modelbased prevalence estimates were calculated for 30 groups based on combinations of age (45, 65, 85 years), gender (female, male), and ECOG PS (04). Prevalence differences between various groups were calculated; values > 10% were empirically classified as clinically important. Result. All three demographic factors were significantly associated with the prevalence of only one symptom, anxiety. The frequency of all eight symptoms decreased with older age. Females had a higher prevalence of nausea, anxiety, and vomiting than males; males had more sleep problems. Prevalence of constipation, sedation, and blackouts was higher with worse PS, whereas both pain and anxiety became less common with worse PS. We observed two major patterns: PS had the largest influence on prevalence, followed by age, then gender. This included pain, constipation, anxiety, sedation, and blackouts. In the second pattern age had the largest influence on prevalence, followed by gender and then PS; this affected sleep problems, nausea, and vomiting. Conclusion. Age, gender, and PS appear to interact with each other and be associated with variations in the prevalence of eight symptoms in advanced cancer. Two major interaction patterns were noted; PS was dominant in one, age in the other.
Vol. 45 No. 2 February 2013
Implications for Research, Policy, or Practice. Awareness of age- and gender-related symptom variations may help develop more effective health care policies and study designs that consider specific patient subgroups.
One Rotation at a Time: Strengthening the Bond Between Anesthesia and Palliative Medicine (S763) Denise Waugh, MD FACEP FAAHPM, Scott and White Healthcare, Temple, TX. (Waugh had no relevant financial relationships to disclose.) Objectives 1. Identify the current ACGME guidelines for anesthesia residency training. 2. Review1 year of experience with a 30 day mandatory Anesthesia intern rotation in Palliative Medicine including both objective and subjective evidence of worth. Background. Although Anesthesia is one of the 10 specialties that supported ABMS certification of Hospice and Palliative Medicine as a subspecialty, the ACGME anesthesia residency teaching requirements do not mention palliative and endof-life care knowledge. Requirements state that the programs should emphasize interpersonal skills and effective communication in addition to acute and chronic pain diagnosis and treatment. Research Objectives. The goal was to improve noninvasive pain management, communication, and interpersonal skills of anesthesia interns. A secondary goal was to improve understanding of endof-life goals and global care needs of patients. Method. Eight anesthesia interns rotated with an interdisciplinary, inpatient PC team for 30 days. They were evaluated by standardized pretest/posttest, follow-up 6 month repeat exam, and by self- assessment of PC competencies. Result. All interns improved their objective knowledge base by an average of 38%. At 6 months, interns retained 60% of the improvement without any additional PC training. Selfassessments revealed confidence in new learning and perception of over-confidence with skills prior to rotation. Conclusion. Anesthesia interns benefited from a mandatory rotation with the PC team. Their knowledge of noninvasive pain management, understanding of communication, and symptom management improved. The interns
Vol. 45 No. 2 February 2013
Poster Abstracts
retained 60% of their improvement at 6 months. All expressed increased comfort with opioid usage, communicating bad news, goals-of-care, and advanced directive discussions.
Implications for Research, Policy, or Practice. Anesthesiologists are expected to be pain specialists. Improving knowledge and skill utilizing goals-of-care and non-invasive pain management may lead to improved care management of both acute and chronic pain. Further research will look at any changes in attitudes toward perioperative DNR decisions in those with and without palliative medicine rotations.
Non-Renal Hospice Eligibility in the Dialysis Population: Utilization and Barriers (S764) Michelle Weckmann, MD, University of Iowa, Iowa City, IA. Jordan Peterson, BA, University of Iowa, Iowa City, IA. Camden Bay, MS, University of Iowa Hospitals and Clinics, Iowa City, IA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. List the three most common reasons patients on dialysis are eligible for hospice, with the exception of renal failure. 2. List two barriers that nephrologists give which decrease hospice referrals. Background. Hospice services are underutilized in the ESRD population when compared with other terminal populations. Hospice eligible patients with a non-renal terminal diagnosis may continue dialysis under Medicare, and with an aging, polymorbid population, these patients may benefit from more hospice involvement. While ESRD patients express a wish to have end-of-life care discussions, these discussions are not commonplace, revealing possible barriers to hospice use. Research Objectives. Identify how many dialysis patients were hospice eligible for non-renal diagnoses and how often patients were engaged in discussions about hospice care. Additionally, nephrologists were interviewed to identify possible barriers to engaging patients in hospice discussions. Method. Chart review of 165 dialysis patients was conducted using a data collection tool based on NHPCO guidelines for hospice eligibility. We
457
collected demographic information including age, sex, race, ethnicity, and comorbid conditions. Nephrologist interview data was analyzed for themes. Result. 17.5% (29/165) patients were eligible for hospice for a non-renal diagnosis. The most prevalent non-renal diagnosis was general decline followed by terminal cardiac disease. Hospice discussions (n ¼ 13, 7.8%) and palliative care consults (n ¼ 14, 8.4%) were uncommon. Patients with evidence of a hospice discussion were an average of 10 years older (60 vs. 70, p ¼ .003). All nephrologists correctly defined hospice care and most understood the Medicare hospice benefit. The most commonly cited barrier to hospice care was perceived patient and family attitudes and discomfort with the topic of hospice. Conclusion. This study identifies a relative lack of hospice discussions compared to the number of hospice eligible patients. Nephrologists interviews suggest this is not necessarily due to knowledge deficits but rather patient and provider readiness to engage in hospice discussions. Possible solutions include early advance care discussions, regular surveillance to identify hospice appropriate patients, and additional education.
Implications for Research, Policy, or Practice. Hospice should be considered more often for dialysis patients.
Utilization of a Standardized Inpatient Hospice Direct Admission Checklist to Improve Transitions of Care (S765) Ryan Westhoff, MD, University of Kansas Medical Center, Kansas City, KS. Lindy Landzaat, DO, University of Kansas Medical Center, Kansas City, KS. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Define an inpatient hospice direct admission process. 2. Describe a checklist tool used to standardize the transition of care of patients being directly admitted to an inpatient hospice facility from a hospital. 3. Discuss how this checklist tool demonstrated improvement in physician comfort with the
Poster Abstracts
Cancer Institute, Cleveland, OH. Lisa Rybicki Cleveland Clinic Foundation, Cleveland, OH. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Recall the three important patient characteristics that influence cancer symptom profile. 2. Learn how to interpret results of cancer treatment and symptom control studies by using the context of patient characteristics Background. To date, the influence of patient demographics on cancer symptom profile has only been studied individually. Research Objectives. To explore the influence of the combined interaction of age, gender, and performance status (PS) on the prevalence of eight cancer symptoms. Method. 38 symptoms were assessed in 1000 consecutive advanced cancer patients. The association of three demographic factors with each symptom was examined using logistic regression analysis. The prevalence of eight symptoms was associated with more than one of the three. Modelbased prevalence estimates were calculated for 30 groups based on combinations of age (45, 65, 85 years), gender (female, male), and ECOG PS (04). Prevalence differences between various groups were calculated; values > 10% were empirically classified as clinically important. Result. All three demographic factors were significantly associated with the prevalence of only one symptom, anxiety. The frequency of all eight symptoms decreased with older age. Females had a higher prevalence of nausea, anxiety, and vomiting than males; males had more sleep problems. Prevalence of constipation, sedation, and blackouts was higher with worse PS, whereas both pain and anxiety became less common with worse PS. We observed two major patterns: PS had the largest influence on prevalence, followed by age, then gender. This included pain, constipation, anxiety, sedation, and blackouts. In the second pattern age had the largest influence on prevalence, followed by gender and then PS; this affected sleep problems, nausea, and vomiting. Conclusion. Age, gender, and PS appear to interact with each other and be associated with variations in the prevalence of eight symptoms in advanced cancer. Two major interaction patterns were noted; PS was dominant in one, age in the other.
Vol. 45 No. 2 February 2013
Implications for Research, Policy, or Practice. Awareness of age- and gender-related symptom variations may help develop more effective health care policies and study designs that consider specific patient subgroups.
One Rotation at a Time: Strengthening the Bond Between Anesthesia and Palliative Medicine (S763) Denise Waugh, MD FACEP FAAHPM, Scott and White Healthcare, Temple, TX. (Waugh had no relevant financial relationships to disclose.) Objectives 1. Identify the current ACGME guidelines for anesthesia residency training. 2. Review1 year of experience with a 30 day mandatory Anesthesia intern rotation in Palliative Medicine including both objective and subjective evidence of worth. Background. Although Anesthesia is one of the 10 specialties that supported ABMS certification of Hospice and Palliative Medicine as a subspecialty, the ACGME anesthesia residency teaching requirements do not mention palliative and endof-life care knowledge. Requirements state that the programs should emphasize interpersonal skills and effective communication in addition to acute and chronic pain diagnosis and treatment. Research Objectives. The goal was to improve noninvasive pain management, communication, and interpersonal skills of anesthesia interns. A secondary goal was to improve understanding of endof-life goals and global care needs of patients. Method. Eight anesthesia interns rotated with an interdisciplinary, inpatient PC team for 30 days. They were evaluated by standardized pretest/posttest, follow-up 6 month repeat exam, and by self- assessment of PC competencies. Result. All interns improved their objective knowledge base by an average of 38%. At 6 months, interns retained 60% of the improvement without any additional PC training. Selfassessments revealed confidence in new learning and perception of over-confidence with skills prior to rotation. Conclusion. Anesthesia interns benefited from a mandatory rotation with the PC team. Their knowledge of noninvasive pain management, understanding of communication, and symptom management improved. The interns
Vol. 45 No. 2 February 2013
Poster Abstracts
retained 60% of their improvement at 6 months. All expressed increased comfort with opioid usage, communicating bad news, goals-of-care, and advanced directive discussions.
Implications for Research, Policy, or Practice. Anesthesiologists are expected to be pain specialists. Improving knowledge and skill utilizing goals-of-care and non-invasive pain management may lead to improved care management of both acute and chronic pain. Further research will look at any changes in attitudes toward perioperative DNR decisions in those with and without palliative medicine rotations.
Non-Renal Hospice Eligibility in the Dialysis Population: Utilization and Barriers (S764) Michelle Weckmann, MD, University of Iowa, Iowa City, IA. Jordan Peterson, BA, University of Iowa, Iowa City, IA. Camden Bay, MS, University of Iowa Hospitals and Clinics, Iowa City, IA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. List the three most common reasons patients on dialysis are eligible for hospice, with the exception of renal failure. 2. List two barriers that nephrologists give which decrease hospice referrals. Background. Hospice services are underutilized in the ESRD population when compared with other terminal populations. Hospice eligible patients with a non-renal terminal diagnosis may continue dialysis under Medicare, and with an aging, polymorbid population, these patients may benefit from more hospice involvement. While ESRD patients express a wish to have end-of-life care discussions, these discussions are not commonplace, revealing possible barriers to hospice use. Research Objectives. Identify how many dialysis patients were hospice eligible for non-renal diagnoses and how often patients were engaged in discussions about hospice care. Additionally, nephrologists were interviewed to identify possible barriers to engaging patients in hospice discussions. Method. Chart review of 165 dialysis patients was conducted using a data collection tool based on NHPCO guidelines for hospice eligibility. We
457
collected demographic information including age, sex, race, ethnicity, and comorbid conditions. Nephrologist interview data was analyzed for themes. Result. 17.5% (29/165) patients were eligible for hospice for a non-renal diagnosis. The most prevalent non-renal diagnosis was general decline followed by terminal cardiac disease. Hospice discussions (n ¼ 13, 7.8%) and palliative care consults (n ¼ 14, 8.4%) were uncommon. Patients with evidence of a hospice discussion were an average of 10 years older (60 vs. 70, p ¼ .003). All nephrologists correctly defined hospice care and most understood the Medicare hospice benefit. The most commonly cited barrier to hospice care was perceived patient and family attitudes and discomfort with the topic of hospice. Conclusion. This study identifies a relative lack of hospice discussions compared to the number of hospice eligible patients. Nephrologists interviews suggest this is not necessarily due to knowledge deficits but rather patient and provider readiness to engage in hospice discussions. Possible solutions include early advance care discussions, regular surveillance to identify hospice appropriate patients, and additional education.
Implications for Research, Policy, or Practice. Hospice should be considered more often for dialysis patients.
Utilization of a Standardized Inpatient Hospice Direct Admission Checklist to Improve Transitions of Care (S765) Ryan Westhoff, MD, University of Kansas Medical Center, Kansas City, KS. Lindy Landzaat, DO, University of Kansas Medical Center, Kansas City, KS. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Define an inpatient hospice direct admission process. 2. Describe a checklist tool used to standardize the transition of care of patients being directly admitted to an inpatient hospice facility from a hospital. 3. Discuss how this checklist tool demonstrated improvement in physician comfort with the