Subject(s)
Airway Extubation , Terminal Care , Humans , Intensive Care Units , Patient Comfort , Respiration, ArtificialSubject(s)
Airway Extubation/adverse effects , Critical Care , Patient Comfort , Terminal Care , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Retrospective Studies , Symptom Assessment , Time Factors , Young AdultABSTRACT
There are few published data on the delivery of palliative care services in the outpatient setting and virtually none on either the integration of palliative care into primary care practice or its applicability to innovative models of health care delivery, such as the patient-centered medical home and accountable care organizations. In this article, new topics for health services delivery research are suggested. Because of the lack of data, the article draws on information collected from inpatient palliative care delivery and includes anecdotal experiences from the outpatient pain medicine and palliative care clinic of an academic department of family medicine.
Subject(s)
Palliative Care/organization & administration , Patient-Centered Care/organization & administration , Primary Health Care/organization & administration , Advance Care Planning , Aged , Chronic Disease/therapy , Health Services Accessibility , Humans , Los Angeles , Male , Population Dynamics , United StatesABSTRACT
We report our experience of providing chronic opioid pharmacotherapy on an outpatient basis to selected patients with frequent episodes of moderate-to-severe pain from sickle cell disease (SCD). Three cases illustrate our clinical experience in approximately 40 patients with sickle cell pain. Patients were seen at our sickle cell pain clinic at Beth Israel Hospital once each month for a three-hour visit. Visits included group music therapy and individual medical care, including comprehensive blood work and scheduling of medical tests when appropriate. Between visits, the pain and palliative care physicians followed patients on an as-needed basis. The SCD pain opioid pharmacotherapy protocol was modeled on a regimen used to treat malignant pain-typically a long-acting opioid in combination with a short-acting opioid, such as oral transmucosal fentanyl citrate (OTFC; Actiq) for breakthrough pain (BTP). Emergency department (ED) visits and hospital admissions were dramatically reduced in the three patients whose pain was managed by adapting the cancer pain model. During the year before their first visit to our pain clinic, the patients each had between six and 18 ED visits, which resulted in six- to 13 hospital admissions amounting to 32-182 inpatient days per patient. Each of the patients was prescribed a long-acting opioid (methadone, control-release oxycodone, or transdermal fentanyl) with a short-acting opioid for BTP from crises (oral transmucosal fentanyl citrate for two patients; short-acting oxycodone for one patient). Pain was well controlled. For each patient, hospital admissions were reduced to < or = 1 visit per year. These reduced levels of ED visits and hospital admissions have remained constant for more than three years.
