Effectiveness of Long-Term Opioid Therapy for Chronic Pain in an Outpatient Palliative Medicine Clinic.

Background: Despite widespread use of opioid therapy in outpatient palliative medicine, there is limited evidence supporting its efficacy and safety in the long term. Objectives: We sought to improve overdose risk scores, maintain pain reduction, and preserve patient function in a cohort with severe chronic pain as we managed opioid therapy for a duration of four years in an outpatient palliative care clinic. Design: Over four years, we provided ongoing goal-concordant outpatient palliative care, including opioid therapy, using quarterly clinical encounters for a patient cohort with chronic pain. Setting/Subjects: The project took place in the outpatient palliative medicine clinic of a regional cancer center in Orlando, Florida (United States). The subjects were a cohort group who received palliative care during the time period between July 2018 and October 2022. Measurements: Key metrics included treatment-related reduction in pain intensity, performance scores, and overall overdose risk scores. Secondary metrics included cohort demographics, average daily opioid use in morphine milligram equivalents and categorization of type of pain. Results: In 97 patients, we observed a stable mean treatment-related reduction in pain intensity of 4.9 out of 10 points over four years. The cohort showed a 2-point (out of 100) improvement in performance scores and an 81-point (out of 999) reduction in mean overall overdose risk score. Conclusions: We present evidence that providing outpatient palliative care longitudinally over four years offered lasting treatment-related reductions in pain intensity, preservation of performance status, and reduction in overall overdose risk.

Criminal prosecutions of physicians providing palliative or end-of-life care.

Although medical malpractice suits commonly occur in medical practice, few physicians experienced criminal prosecution related to adverse clinical outcomes before 1990. Criminal prosecutions of physicians increased in frequency early in that decade, however, including a handful of cases involving palliative or end-of-life care. Reviews published around the end of the 1990s examined those prosecutions, listing causative factors and offering recommendations to prevent further cases. In this paper, we provide an updated review of criminal prosecutions of physicians providing palliative or end-of-life care, presenting three cases that occurred after 1998. We summarize these newer cases' chronologies and outcomes, comparing them to cases described in past reviews. Our analysis suggests that important factors not described in earlier reviews, especially conflicting views of the standard of care in hospice and palliative medicine, contributed to the development of these prosecutions.

Evolving medicolegal issues in palliative medicine.

The successful practice of hospice and palliative medicine requires basic knowledge of its medicolegal aspects. In this paper, we review several recent legal cases that highlight important, evolving legal issues in palliative medicine. These issues include efforts to change to advance directive laws after the Schiavo conflict, the Attorney General's challenge to Oregon's physician-assisted dying law, and the emergence of a tort for inadequate pain management. Despite conflicting attitudes about key issues in end-of-life care, the courts' decisions in these cases have consistently advanced the interests of hospice and palliative care practitioners.

Closing the Schiavo case: an analysis of legal reasoning.

The conflict surrounding Terri Schiavo, whom Florida's courts had determined wished not to be kept alive in a persistent vegetative state, played out on a national stage. The dispute between Schiavo's husband and parents engulfed America's legislative, executive, and judicial systems, raising profound questions about the laws and policies that govern advance directives. In this paper, we offer an analysis of the legal reasoning in Schiavo and offer predictions about the case's likely impact on law and policy in the future. We reviewed an extensive collection of case materials that included consensus definitions of persistent vegetative state, media reports, court decisions and briefs, legal chronologies, guardian reports, and Schiavo's autopsy report. We also reviewed cases cited as sources for legal reasoning used in Schiavo, including Quinlan, Cruzan, and Browning. We also examined the political, cultural, and media factors that affected the conflict. Based upon these reviews, we identified the legal reasoning that decided the Schiavo conflict. We found that Florida's constitutional right to privacy, a principle that shaped the Florida statutory and case law, guided the courts' consistent rulings. The conflict that characterized the case reflected profound differences in American politics rather than a failure of the medical and/or legal systems. The outcome of the Schiavo case remained consistent with established Florida statutory and case law, and honored Terri Schiavo's state constitutional right to privacy. Although Schiavo may not affect advance directive law and policy in palliative medicine immediately, evidence suggests it has already increased interest in creating living wills.