Caring About Residents' Experiences and Symptoms (CARES) Program: A Model of Palliative Care Consultation in the Nursing Home.

OBJECTIVES: To describe the CARES program, a model of palliative care for nursing home residents. DESIGN: Descriptive analysis of the Caring About Residents' Experiences and Symptoms (CARES) Program that provides palliative care services to nursing home residents. PROGRAM EVALUATION: The CARES Program serves as an example of collaborative efforts to meet community needs. To evaluate the program, we document the services provided as well as process outcomes (changes to care plans, hospitalizations, location of death, and hospice utilization) for residents referred. RESULTS: 170 nursing home residents were seen by CARES Program between February 2013 to December 2015, 48% for skilled services, and 52% for long term care. Majority of referrals were for goals of care and concurrent symptom management. Following consultation, 67% of residents had a change in code status. Of residents desiring a palliative course 90% were never hospitalized. Overall, 53% of residents died; and those in long term care dying more often with hospice. CONCLUSION: The CARES program of palliative consultation addresses the needs of nursing home residents. The model has potential to be reproducible in in other communities.

Dying With Dyspnea in the Hospital.

BACKGROUND: While many patients hope to die at home, many die in hospitals. Patients die with unrecognized and untreated symptoms including dyspnea. OBJECTIVE: We sought to determine prevalence of dyspnea at end of life in patients dying in acute hospital care and examine treatment patterns. DESIGN/PARTICIPANTS: A retrospective chart review of deaths at tertiary care hospital over a 3-month period evaluated dyspnea in last 24 hours of life, opioid orders and administration as well as presence of palliative care consultation. RESULTS: Of 106 decedents, 88 experienced dyspnea or tachypnea in last 24 hours of life. Health care providers noted only 50% as dyspneic, even those undergoing terminal comfort extubation. Almost all patients with dyspnea documented by staff had orders and received opioids; however, few orders described treatment specifically for dyspnea. Patients with palliative care consultations more often received opioids ( P = .0007), and opioid orders more often specified treatment of dyspnea ( P = .013). CONCLUSION: These findings support that previous work noting many patients experience dyspnea at end of life. Despite national guidelines, health care providers may still be underrecognizing and likely not optimally treating dyspnea at the end of life in the hospital. Collaboration with palliative medicine providers may improve assessments and treatments for quality end-of-life care for hospitalized patients.

Opioids for persistent pain in older adults.

Older adults compose a large portion of patients with persistent pain. Opioid analgesics are widely used to treat acute and persistent pain in cancer and end-of-life care, but their use in other types of persistent pain in older adults is controversial. Clinicians and regulators must work together, balancing the legitimate medical need for opioids while acknowledging increasing opioid misuse and morbidity and mortality related to opioids.

The EVMS pain education initiative: a multifaceted approach to resident education.

UNLABELLED: Chronic pain is a major health issue that causes significant patient morbidity as well as economic loss. Many studies have highlighted the lack of training in chronic pain management for resident physicians and the need to develop programs that address the challenges of providing care to chronic pain patients. We wanted to determine whether a workshop using a combination of standardized patients, small groups, and large group lectures addresses residents' curricular needs regarding chronic pain management. We developed a 1-day workshop for residents at Eastern Virginia Medical School, which has a nationally recognized professional skills center. After completing the workshop, residents showed significant gains in knowledge (post-test vs pre-test overall mean +23.4%, P < .001). Significant gains in clinical skills were also seen (overall +5.9%, P < .001) with improvements in the areas of pain assessment (+6.3%, P < .001), physical examination (+7.7%, P < .03), and pain management (+8%, P < .01). Physicians also reported increased comfort regarding chronic pain management. Almost all residents stated they would make specific practice changes in the assessment and management of chronic pain patients. The results suggest our workshop is a novel model that is effective in teaching residents how to assess and manage chronic pain. PERSPECTIVE: This article demonstrates that the use of standardized patients with other teaching methods is an effective approach in teaching resident physicians regarding the assessment and management of chronic pain patients. The findings have the potential to restructure our methods of teaching in chronic pain education.

Use of PEG tubes in the cognitively impaired patient: dispelling the myths.

Difficulty eating is one of the markers of end-stage dementia and poses difficult care decisions for family members and health care providers. In particular, family members often struggle with the decision of whether to provide artificial nutrition via feeding tube. While it is important that surrogate decision makers be provided with information on the risks and benefits of artificial nutrition, studies have shown that many health care providers are misinformed about the rationale for recommending a percutaneous endoscopic gastrostomy tube. Current literature suggests that for the elderly patient with dementia there is little clinical evidence that artificial nutrition provides any benefit to the patient.

Persistent pain in the elderly.

Persistent pain is a challenging problem in the elderly and is not a normal process in aging. Successful management of persistent pain can be achieved through comprehensive assessment, use of routine pain medication and careful monitoring of medical functional status.