Literature Review

Clinical scenario: Patient care through POLST  The Hospitalist; by Mihir Patel, MD, MPH, FACP, CLHM, SFHM; 10/10/24 Physician orders for life-sustaining treatment (POLST) forms are crucial tools in ensuring that patient treatment preferences are respected and followed, particularly during medical emergencies. As hospitalists, integrating POLST into patient care can significantly enhance decision-making processes, aligning treatments with the patient’s wishes. Here, we present a clinical scenario demonstrating the application of POLST in a hospital setting, emphasizing the importance of electronic documentation in the patient’s medical record. ... [Click on the title's link for this Case Study, which includes the Case, Hospitalist Actions,Outcome, and Conclusion.]

How to prepare yourself for death when given a terminal diagnosis Yahoo!Life; by Kate Ng; 10/8/24 Receiving a terminal diagnosis can be a devastating blow, for the individual and their loved ones. There is no right or wrong way to react to such news, and people respond with all sorts of emotions - from anger and denial, to acceptance and peace. Having a terminal illness can also give a person new perspective. ...

Caring for Hindu patients at the end-of-life: A narrative review Cambridge University Press; by Brinda Raval Raniga, MD, Savannah Kumar, MD, Rebecca McAteer Martin, MD, and Craig D. Blinderman, MD; 10/3/24  This paper reviews the existing literature to identify specific challenges that may arise in the context of providing palliative and end-of-life (EOL) care for Hindu patients in the physical, psychological, and spiritual domains. We offer practical strategies where appropriate to mitigate some of these challenges. We review how the Hindu faith impacts EOL decision-making, including the role of the family in decision-making, completion of advance directives, pain management, and decisions around artificial nutrition and hydration (ANH) and cardiopulmonary resuscitation (CPR). 

Hospitalists use POLST to initiate patient conversations about care goals The Hospitalist; by Larry Beresford; 10/1/24 Physician orders for life-sustaining treatment (POLST) is a single-page medical order form, typically printed on bright pink paper, and signed by a physician, nurse practitioner, or physician assistant to spell out treatment preferences for a seriously ill or frail patient. It is also a process for exploring those preferences in conversation with patients and then communicating them to those who might need to know, such as EMS personnel, in some future medical emergency when the patients can no longer speak for themselves. And, said Steven Pantilat, MD, FAAHPM, MHM, a former clinical hospitalist and the inaugural chief of the division of palliative medicine at the University of California San Francisco, it is “solidly within what hospitalists can and should be doing.” That may involve meeting and talking with patients and their families about their values and treatment preferences, reviewing any existing POLST forms, and even filling out and signing a form.

AI shouldn't decide who dies. It's neither human nor humane Fox News; by John Paul Kolcun and Anthony Digiorgio; 9/20/24 [Opinion] As we write this, PubMed ... indexes 4,018 publications with the keyword "ChatGPT." Indeed, researchers have been using AI and large-language models (LLMs) for everything from reading pathology slides to answering patient messages. However, a recent paper in the Journal of the American Medical Association suggests that AI can act as a surrogate in end-of-life discussions. This goes too far. The authors of the paper propose creating an AI "chatbot" to speak for an otherwise incapacitated patient. To quote, "Combining individual-level behavioral data—inputs such as social media posts, church attendance, donations, travel records, and historical health care decisions—AI could learn what is important to patients and predict what they might choose in a specific circumstance." Then, the AI could express in conversant language what that patient "would have wanted," to inform end-of-life decisions. We are both neurosurgeons who routinely have these end-of-life conversations with patients’ families, as we care for those with traumatic brain injuries, strokes and brain tumors. These gut-wrenching experiences are a common, challenging and rewarding part of our job. Our experience teaches us how to connect and bond with families as we guide them through a life-changing ordeal. In some cases, we shed tears together as they navigate their emotional journey and determine what their loved one would tell us to do if they could speak. 

It pays to know: How to be an effective health care agent The Rafu Shimpo; by Judd Matsunaga, Esq; 9/12/24 Being asked to be someone’s health care agent is a special honor — it means the person is saying, “I trust you with my life.” That said, it’s also a huge responsibility. As a health care agent, you will be in charge of making healthcare decisions for your loved one when they can no longer make decisions for themselves. ... Advance care planning is a process. It’s not something that gets done all at once. To help you be an effective health care agent, here are some questions you can ask your loved one: (Source: www.mskcc.org, “How to Be a Health Care Agent”)

Why so many patients are confused about CPR and do-not-resuscitate orders STAT; by Lindsey Ulin; 9/11/24 Inherently difficult conversations are made more so by a lack of physician training. When a patient is admitted to the hospital in the U.S., there’s a standard question physicians like me are supposed to ask: “If your heart stops beating, do you want us to do CPR?” On the surface, this may seem like a mechanic asking a customer, “If your car stalls, do you want us to jumpstart the engine?” Who would say no to this, especially in a hospital? The problem is that this exchange, which we call asking about “code status” in medicine, centers around a closed-ended question. Talking to a patient about their preferences for cardiac resuscitation, intubation, and/or other life-sustaining treatments needs to be a complete, often lengthy discussion, not just a box to check. ...

Feasibility of a serious illness communication program for pediatric advance care planningJAMA Open Newtwork; Danielle D. DeCourcey, MD, MPH; Rachelle E. Bernacki, MD, MS; Brett Nava-Coulter, MPH; Sithya Lach, BS; Niya Xiong, MSPH; Joanne Wolfe, MD, MPH; 7/24Children and adolescents and young adults (AYAs) with serious illness often have a variable clinical course with periods of stability alternating with life-threatening deteriorations; consequently, many children and AYAs experience health crises without opportunities to discuss preferences for medical care. Furthermore, bereaved parents report a lack of preparation to address their child’s medical and emotional needs at end of life (EOL). Advance care planning (ACP) is an iterative process to honor patient and family goals and values involving communication about prognosis and the formulation of care plans addressing symptom management, quality of life, preferences for life-sustaining interventions, and anticipatory guidance about EOL. Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon. This pilot cohort study found that the PediSICP [Pediatric Serious Illness Communication Program] was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness.

Doctors saved her life. She didn’t want them to. DNYUZ; by Kate Raphael;  8/26/24 Marie Cooper led her life according to her Christian faith. ... [And, she] always said that at the end of her life, she did not want to be resuscitated. ... Last winter, doctors found cancer cells in her stomach. She’d had “do not resuscitate” and “do not intubate” orders on file for decades and had just filled out new copies, instructing medical staff to withhold measures to restart her heart if it stopped, and to never give her a breathing tube. In February, Ms. Cooper walked into the hospital for a routine stomach scope to determine the severity of the cancer. After the procedure, [Ms. Cooper's daughter] visited her mother in the recovery room and saw her in a panic. ... [The daughter] called for help and was ushered to a waiting room while the medical team called an emergency code. Ms. Cooper grew even more distressed and “uncooperative,” according to medical records. Doctors restrained her and inserted a breathing tube down her throat, violating the wishes outlined in her medical chart. Ms. Uphold, livid, confronted the doctors, who could not explain why Ms. Cooper had been intubated. ... 

Mid-Atlantic primary care providers’ perception of barriers and facilitators to end-of-life conversationPalliative Care and Social Practice; by Melanie A. Horning, Barbara Habermann; 8/24Primary care providers are ideal people to facilitate end-of-life conversations, but these conversations rarely occur in the out-patient setting. Reported barriers in descending order included resistance from patients and families, insufficient time, and insufficient understanding of prognosis and associated expectations. Reported facilitators in descending order included established trusting relationship with provider, physical and/or cognitive decline and poor prognosis; and discussion standardization per Medicare guidelines. The involvement of primary care providers is associated with earlier ACP [advance care planning].

Hospice care for those with dementia falls far short of meeting people’s needs at the end of life University of Michigan; by Maria J. Silveira; 8/18/24 ... Strikingly, only 12% of Americans with dementia ever enroll in hospice. Among those who do, one-third are near death. This is in stark contrast to the cancer population: Patients over 60 with cancer enroll in hospice 70% of the time. In my experience caring for dementia patients, the underuse of hospice by dementia patients has more to do with how hospice is structured and paid for in the U.S. than it does patient preference or differences between cancer and dementia. ... In the U.S., ... Medicare’s rules and regulations make it hard for dementia patients to qualify for hospice when they and their families need support the most – long before death. In Canada, where hospice is structured entirely differently, 39% of dementia patients receive hospice care in the last year of life. ...

Factors associated with Do Not Resuscitate status and palliative care in hospitalized patients: A national inpatient sample analysis Palliative Medicine Reports; by Jean-Sebastien Rachoin, Nicole Debski, Krystal Hunter, Elizabeth CerceoIn the United States, the proportion of hospitalized patients with DNR, PC, and DNR with PC increased from 2016 to 2019. Overall, inpatient mortality and LOS fell, but hospital charges per patient increased. Significant gender and ethnic differences emerged. Black patients and males were less likely to have DNR status and had higher inpatient mortality, LOS, and hospital charges.

Teleios’ Clinically Integrated Network Sets Benchmark for Healthcare ExcellenceTeleios press release; 7/31/24Teleios Collaborative Network (TCN) recently announced that its Clinically Integrated Network (CIN) is setting the benchmark for healthcare excellence in the serious illness space. The data from the most recent reporting period again demonstrates that the members of the CIN are delivering exceptional patient care. One hundred percent of the CIN members achieved a 4- or 5-star rating on the CAHPS Hospice Survey Star Ratings by CMS. In addition, all the members identified and documented a healthcare surrogate for hospice within the first 5 days after admission at least 90% of the time with the network average being 97% and upon the time of admission for Palliative Care patients with the average being 99.8% of the time. This was the result of the members reviewing and revising their processes to ensure that a healthcare surrogate was identified and documented.