An Educational Needs Assessment for Outpatient Palliative Care Clinicians.

Introduction: As the field of palliative medicine continues to grow in community-based settings, outpatient palliative care clinics have become an important site for providing upstream palliative care to patients and families. It is unclear whether current training models, focused predominantly on the inpatient setting, adequately prepare clinicians for outpatient palliative care practice. Methods: We performed an online educational needs assessment survey of physicians and advanced practice providers working in outpatient palliative care clinics. Survey questions focused on the importance of specific palliative care knowledge, skills, and attitudes in outpatient practice using the Accreditation Council of Graduate Medical Education Hospice and Palliative Medicine (HPM) curricular milestones to guide survey development. We also explored clinician perception of training adequacy and current educational needs relevant to outpatient practice. Results: One hundred sixty-four clinicians, including 122 (74.4%) physicians, 32 (19.5%) nurse practitioners, and 8 (4.9%) physician assistants, completed our survey. Clinicians had a median of 10 years of HPM experience and 6 years of outpatient experience. We identified two main areas of perceived knowledge or skill deficit: navigating insurance and prior authorizations and co-management of pain and opioid use disorder. Conclusion: Addressing gaps in education and preparedness for outpatient practice is essential to improve clinician competence and efficiency as well as patient care, safety, and care coordination. This study identifies practice management and opioid stewardship as potential targets for educational interventions. The development of curricula related to these outpatient skills may improve clinicians' ability to provide safe, patient-centered care with confidence.

Opioid-Sparing Effects of Topical Ketamine in Treating Severe Pain From Decubitus Ulcers.

Pain from pressure ulcers can severely impact a patient's quality of life. Evidence-based treatment of ulcer-related pain typically relies on systemic opioids with limiting side effects. Literature exists on the use of topical ketamine for neuropathic pain, but not for tissue injury in general and for decubitus ulcer pain specifically. Ketamine has a number of actions including blocking of the glutamate NMDA ionophore in the periphery. Preclinical evidence suggests that NMDA receptors located on peripheral sensory afferent terminals may play a role in initiating pain signaling in inflamed tissues. Topical ketamine, therefore, has the potential to provide analgesia when applied to decubitus ulcers. Here a case is reported of a 54-year-old female with diffuse large B-cell lymphoma who during a critical period in her illness experienced gangrene leading to chronic bilateral stage IV decubitus heel ulcers. The severe pain reported by the patient was poorly managed using high doses of systemic opioids and resulted in intermittent systemic side effects. Adding a compounded ketamine gel to her wound dressings twice daily over an interval of several months drastically reduced her opioid use and, more important, her pain, with minimal side effects.