Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic.

OBJECTIVES: A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic. DESIGN: We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021. SETTING: Two academic medical centers in the Chicago metropolitan area. PATIENTS: Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7). CONCLUSIONS: In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.

Integrating specialist palliative care to improve care and reduce suffering: cystic fibrosis (InSPIRe:CF) - study protocol for a multicentre randomised clinical trial.

INTRODUCTION: Cystic fibrosis (CF) is a life-limiting genetic disorder estimated to affect more than 160 000 individuals and their families worldwide. People living with CF commonly experience significant physical and emotional symptom burdens, disruptions to social roles and complex treatment decision making. While palliative care (PC) interventions have been shown to relieve many such burdens in other serious illnesses, no rigorous evidence exists for palliative care in CF. Thus, this study aims to compare the effect of specialist palliative care plus usual CF care vs usual CF care alone on patient quality of life. METHODS AND ANALYSIS: This is a five-site, two-arm, partially masked, randomised superiority clinical trial. 264 adults with CF will be randomly assigned to usual CF care or usual CF care plus a longitudinal palliative care intervention delivered by a palliative care specialist. The trial's primary outcome is patient quality of life (measured with the Functional Assessment of Chronic Illness Therapy-Palliative care instrument). Secondary outcomes include symptom burden, satisfaction with care and healthcare utilisation. Outcomes will be measured at 12 months (primary endpoint) and 15 months (secondary endpoint). In addition, we will conduct qualitative interviews with patient participants, caregivers, and palliative care and CF care team members to explore perceptions of the intervention's impact and barriers and facilitators to dissemination. ETHICS AND DISSEMINATION: Human subjects research ethics approval was obtained from all participating sites, and all study participants gave informed consent. We will publish the results of this trial in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN53323164.

Serious Illness Communication Skills Training during a Global Pandemic.

Background: Communication skills is a core competency for critical care fellowship training. The coronavirus disease (COVID-19) pandemic has made it increasingly difficult to teach these skills in graduate medical education. We developed and implemented a novel, hybrid version of the Critical Care Communication (C3) skills with virtual and in-person components for pulmonary and critical care fellows. Objective: To develop and implement a new hybrid virtual/in-person version of the traditional C3 serious illness communication skills course and to compare learner outcomes to prior courses. Methods: We modified the C3 course in 2020 in response to the COVID-19 pandemic by adapting large-group didactic content to an online format that included both virtual asynchronous and virtual live content. Small-group skills training remained in person with trained actors and facilitators. We administered self-assessments to the participants and compared with historical data from the traditional in-person courses beginning in 2012. After the 2020 course, we collected informal feedback from a portion of the learners. Results: Like the traditional in-person version, participants rated the hybrid version highly. Learners reported feeling well prepared or very well prepared over 90% of the time in most communication skills after both versions of the course. Over 90% of participants in both versions of the course rated the specific course components as effective or very effective. Feedback from the learners indicates that they prefer the virtual didactics over traditional in-person didactics. Conclusions: Pulmonary and critical care fellows rated a hybrid version of a communication skills training similarly to the traditional in-person version of the course. We have provided a scaffolding on how to implement such a course. We anticipate some of the virtual components of this training will outlive the current pandemic based on learner feedback.

Palliative Care Exposure and Career Development Mentoring for Medical Students from Underrepresented Backgrounds and Schools That Lack Access to Palliative Care (FR253)

Outcomes 1. Describe palliative care training at schools with high numbers of underrepresented (UR) medical students 2. Explain key components of a palliative care summer research program for students from UR backgrounds and schools that lack access to palliative care 3. Develop action items to enhance palliative care exposure and training for UR medical students across the United States Many medical schools across the United States lack access to palliative care educational opportunities. This is especially true at historically Black colleges and universities (HBCUs) and predominantly Latino-serving institutions that generally are not resource rich. Opportunities for exposure to palliative care during medical school have two purposes. First, it can increase diversity by encouraging students who are underrepresented (UR) to specialize in palliative care. Second, UR physicians are more likely to care for patients who look like them. Therefore, improving palliative care training can enhance the care that UR patients with serious illness receive. Given the shortage of specialty-trained palliative care physicians, providing opportunities to introduce palliative care early in medical training will help to enhance primary palliative care skills for these future physicians. In this concurrent session, we will first discuss the limited options that schools with high numbers of UR students have to obtain palliative care training. Next, we will discuss an innovative palliative care summer research and career development program for medical students from UR backgrounds and schools that lack access to palliative care. In thinking through the program, we will lead a discussion with participants regarding the core knowledge, skills and attitudes that should guide a palliative care summer program for medical students. We will then describe the pilot program we have developed at the University of Pittsburgh and discuss feedback from the initial cohort class. Financial, staff, and other barriers, particularly in the time of COVID, will be shared, with possible solutions. The goal will be to help programs develop action items to improve palliative care exposure and multidisciplinary mentorship for medical students from UR backgrounds and schools that do not have a palliative care program.

The Impact of Virtual Interviews on Recruitment in Hospice and Palliative Medicine Fellowship Training.

CONTEXT: The ongoing COVID-19 pandemic has led many leaders to reassess how recruitment into the medical field is conducted. In Hospice and Palliative Medicine, many training programs are moving to virtual recruitment as a more permanent strategy. However, virtual recruitment disproportionately affects smaller training programs as well as those in smaller cities or those whose location is less well-known. OBJECTIVES: To assess faculty perspective regarding the value of virtual vs. face-to-face recruitment methods in a well-established program located in a mid-sized city that is lesser known than many comparable programs. METHODS: After virtual recruitment season in 2020, we assessed our faculty regarding the process of virtual interviews. Survey items were based on results of the 2020 NRMP Internal Medicine Program Director Survey to include the most highly cited factors used to rank internal medicine applicants. Faculty was asked whether virtual or face-to-face interviews were more effective and were asked to make an overall choice between face to face and virtual recruitment formats and to explain the reason behind their decision. RESULTS: Twenty-three faculty received the survey and 17 completed. Although more faculty felt that in-person interviews allowed for better ability to recruit the most qualified trainees than virtual interviews, nine out of the 17 faculty chose virtual as their preferred format. CONCLUSION: While acknowledging benefits that can only be achieved in-person, our faculty believe that virtual interviews for future Hospice and Palliative Medicine fellows is an effective and potentially advantageous way to recruit the future work force of Hospice and Palliative Medicine.

Addressing Food-Energy-Water Insecurities of the Navajo Nation through University-Community Collaboration

In the US, COVID-19 is rampant within the Navajo Nation the largest tribe in the US, where the rate of poverty (38%) is more than twice that of the state of Arizona (15%). Navajo tribal officials cite the lack of healthy foods and running water as reasons for the prolific virus transmission, resulting in one of the highest COVID-19 infection rates in the US. Partnerships, including those involving research and education, are critical to addressing food, energy, and waste (FEW) insecurities in Native American communities. Over time, integrated, connected, resilient FEW units for remote Dine communities will provide efficient, economically achievable opportunities for dispersed water purification capacity and food-producing greenhouse technology powered by solar energy. Through university-community partnerships involving robust community engagement, technologies can be deployed in remote ocations as well as more urbanized locations.

Drive-by Photoscreening: Plusoptix, 2WIN and Blinq Amblyopia Detection During the COVID-19 Pandemic.

BACKGROUND: Community photoscreening for amblyopia had successfully been adopted by many communities, however many clinics curtailed screening as a result of the COVID-19 pandemic. We modified three conventional devices and tested them for outdoor, drive-by socially distanced photoscreening and refraction. METHODS: External frames that provide luminance control and focus distance were fashioned for plusoptiX S12 (Nuremberg, Germany), Adaptica 2WIN in Kaleidos case (Padova, Italy) and the Rebion blinq (Boston, USA). Children were screened by each device and then Retinomax (Righton, Japan) before AAPOS guideline validation. RESULTS: Eighty-eight children average age 8±7 years had precise refraction and alignment from which 69% AAPOS 2003 risk factors were determined. The sensitivity/specificity/inconclusive rate for plusoptiX was 85%/96%/16%, for 2WIN 79%/89%/5% and for blinq 43%/74%/8%. Blinq improved to 54%/70% when screening for amblyopia ± strabismus. Bland Altman analysis of spherical equivalent showed plusoptiX and 2WIN with less over-minus than Retinomax and J0 and J45 vectors highly reliable for astigmatism determination. CONCLUSION: The infrared photorefractors in modified cases reliably screened amblyopia risk factors and refraction. The birefringent scanner provided drive-by results but less reliably with wire-frame opaque case than without the case in a dimly lit room. Modified drive-by photoscreeners could help reduce amblyopia and provide socially distanced refraction during an extended pandemic.