Opioid Management Review Committee: Fostering Interdisciplinary Education and Support Amid the Ongoing US Opioid Overdose Crisis.

BACKGROUND: Over the past two decades, pain and suffering caused by the U.S. opioid crisis have resulted in significant morbidity, policy reforms and healthcare resource strain, and affected healthcare providers' efforts to manage their patients' pain. In 2017, Cleveland Clinic's Department of Palliative and Supportive Care established their Opioid Management Review Committee (OMRC), which focuses on patient safety, opioid stewardship, education on specialist pain management and addiction medicine skills, and offers emotional and informational support to colleagues managing complex pain cases. OBJECTIVES: This quality assessment and improvement activity describes the organization and effects of the OMRC on healthcare workers in the department. METHODS: On February 1, 2023, an online survey was distributed to attendees of the OMRC. Participants were asked to provide their demographic information and free text responses to questions about the purpose of the OMRC, their judgment about the extent to which the OMRC has changed their approach to pain management, the OMRC's impact on their approach to opioid management, its impact on the clinicians' confidence in managing nonmedical opioid use or comorbid substance use, and suggestions to improve future meetings. RESULTS: Fifty-nine out of 79 clinicians completed the survey (75% response rate). Participants' aggregate responses indicated that the committee fostered interdisciplinary collaboration, provided emotional and professional support, increased awareness of responsible opioid prescribing, and enhanced confidence in managing complex cases involving non-medical opioid use or comorbid substance use. CONCLUSION: The OMRC represents a comprehensive interdisciplinary approach to safely manage opioid therapy during the contemporary opioid overdose crisis.

Health Professionals' Perceptions of the Contributions of Palliative Care Consultation for Patients with COVID-19.

Background: Palliative care (PC) programs worldwide are involved in caring for patients with coronavirus disease 2019 (COVID-19) with other professionals. Objectives: To determine health professionals' perceptions of the contributions of PC in COVID-19 care, and describe its effect on professionals' psychological distress. Design: Cross-sectional study. Setting/Subjects: Physicians, advance practice providers, nurses, and case managers at two hospitals. Measurements: Seventeen-item questionnaire on demographics, contributions of PC, and psychological distress. Results: Of 427 health professionals invited to participate, 76 responded (18%). Among 64 eligible respondents, 72% were female, 56% were under the age 40, 40.6% were nurses, 28.1% were physicians, and 66% worked in the intensive care unit. The PC team was perceived as helpful in managing pain and other symptoms, coordinating care among providers, discussing end-of-life preferences, communicating with patients and families and supporting the care team. Median self-reported psychological distress was 7 (range 2-10). Twenty-five (39%) participants agreed that PC eased distress by communicating with patients, families, and other professionals, providing guidance in difficult conversations and offering companionship. Among respondents, 84% would likely work with PC in the future. Conclusions: During the COVID-19 pandemic, health professionals perceived PC as helpful in caring for patients and families, and in easing their own psychological distress.

The role of palliative care in COVID-19.

In light of the COVID-19 pandemic, many healthcare systems are experiencing an increased demand for palliative care (PC). To meet this challenge, the PC team at Cleveland Clinic designed an enterprise-wide response plan organized around 4 domains: staff (educational resources and tools), stuff (medications and supplies), space (recommendations for optimizing physical space and facilities), and systems to facilitate high-quality PC delivery to patients. To mitigate isolation during end-of-life care, the Clinic offers "compassionate exceptions" to strict visitation policies, provides personal protective equipment to visitors of these patients, and facilitates virtual visitation via electronic devices.

Early Integrated Telehealth versus In-Person Palliative Care for Patients with Advanced Lung Cancer: A Study Protocol.

Introduction: Early palliative care (PC) integrated with oncology care improves quality of life (QOL), depression symptoms, illness understanding, and end-of-life (EOL) care for patients with advanced lung cancer. The aims of this trial are to compare the effect of delivering early integrated PC through telehealth versus in-person on patient and caregiver outcomes. We hypothesize that both modalities for delivering early PC would be equivalent for improving patient QOL, communication about EOL care preferences with their oncologist, and length of stay in hospice. Methods: For this comparative effectiveness trial, we will enroll and randomize 1250 adult patients with advanced nonsmall cell lung cancer (NSCLC), who are not being treated with curative intent, to receive either early integrated telehealth or in-person PC at 20 cancer centers throughout the United States. Patients may also invite a family caregiver to participate in the study. Patients and their caregivers in both study groups meet at least every four weeks with a PC clinician from within 12 weeks of patient diagnosis of advanced NSCLC until death. Participants complete measures of QOL, mood, and quality of communication with oncologists at baseline before randomization and at 12, 24, 36, and 48 weeks. Information on health care utilization, including length of stay in hospice, will be collected from patients' health records. To test equivalence in outcomes between study groups, we will compute analysis of covariance and mixed linear models, controlling for baseline scores and study site. Study Implementation and Stakeholder Engagement: To ensure that this comparative effectiveness trial and findings are as patient centered and meaningful as possible, we have incorporated a robust patient and stakeholder engagement plan. Our stakeholder partners include (1) patients/families, (2) PC clinicians, (3) telehealth experts and clinician users, (4) representatives from health care systems and medical insurance providers, and (5) health care policy makers and advocates. These stakeholders will inform and provide feedback about every phase of study implementation.

A pilot study of palliative medicine fellows' hospice home visits.

This was a prospective descriptive study of hospice physician home visits (HVs) conducted by Hospice and Palliative Medicine Fellows. Our objectives were 1) to improve our knowledge of hospice care at home by describing physician HVs 2) to identify the indications for physician HVs and the problems addressed during the HV. Data was collected on 58 consecutive patients using a standardized form completed before and after the home visit. More than half of the persons were women. Most were Caucasian. Median age was 75 years; 57% had cancer; 77% were do-not-resuscitate. 76% HV occurred in the home. The median visit duration was 60 minutes; median travel distance and time 25 miles and 42 minutes, respectively. A hospice nurse case manager was present in 95%. The most common issues addressed during HVs were: health education, symptom management, and psychosocial support. Medication review was prominent. Physicians identified previously unreported issues. Symptom control was usually pain, although 27 symptoms were identified. Medications were important; all home visits included drug review and two thirds drug change. Physicians had unique responsibilities and identified important issues in the HV. Physicians provided both education and symptom management. Physician HVs are an important intervention. HVs were important in continuity of care, however, time-consuming, and incurred considerable travel, and professional time and costs.

Symptom management: an important part of cancer care.

Physicians can do a better job of palliating symptoms and improving the quality of life of cancer patients if they understand the principles of symptom management. We review the general principles of symptom management for fatigue, anorexia, constipation, dyspnea, nausea, and vomiting.

Development and evaluation of a new taxonomy of mobility-related assistive technology devices.

OBJECTIVE: This article reports on the development of a new taxonomy for mobility-related assistive technology devices. DESIGN: A prototype taxonomy was created based on the extant literature. Five mobility device experts were engaged in a modified Delphi process to evaluate and refine the taxonomy. RESULTS: Multiple iterations of expert feedback and revision yielded consensual agreement on the structure and terminology of a new mobility device taxonomy. The taxonomy uses a hierarchical framework to classify ambulation aids and wheeled mobility devices, including their key features that impact mobility. Five attributes of the new taxonomy differentiate it from previous mobility-related device classifications: (1) hierarchical structure, (2) primary device categories are grouped based on their intended mobility impact, (3) comprehensive inclusion of technical features, (4) a capacity to assimilate reimbursement codes, and (5) availability of a detailed glossary. CONCLUSIONS: The taxonomy is intended to support assistive technology outcomes research. The taxonomy will enable researchers to capture mobility-related assistive technology device interventions with precision and provide a common terminology that will allow comparisons among studies. The prominence of technical features within the new taxonomy will hopefully promote research that helps clinicians predict how devices will perform, thus aiding clinical decision making and supporting funding recommendations.

Nausea and vomiting in advanced cancer.

Nausea and vomiting are relatively common in advanced cancer and is dreaded more than pain by patients. The history, pattern of nausea and vomiting, associated symptoms, and physical examination provides clues as to etiology and may guide therapy. Continuous severe nausea unrelieved by vomiting is usually caused by medications or metabolic abnormalities, while nausea relieved by vomiting or induced by eating is usually due to gastroparesis, gastric outlet obstruction, or small bowel obstruction. Drug choices are empiric or based on etiology. Metoclopramide has the greatest evidence for efficacy followed by phenothiazines and tropisetron. Corticosteroids have not been effective in randomized trials except in the case of bowel obstruction. Treatment of nausea unresponsive to first-line medications involves rotation to medications which bind to multiple receptors (broad-spectrum antiemetics), the addition of another antiemetic to a narrow-spectrum antiemetic (a serotonin receptor antagonist such as tropisetron to a phenothiazine), rotation to a different class of antiemetic (tropisetron for a phenothiazine), or in-class drug rotation. Venting gastrostomy, octreotide, and corticosteroids will reduce nausea and vomiting associated with malignant bowel obstruction.

Mobility-related assistive technology device classifications: implications for outcomes research.

This article evaluates six mobility-related device classifications for their ability to support assistive technology outcomes research. Our evaluation considered classifications that had been created for various purposes, including those created to support third-party reimbursement decisions, consumer education and safety, and research. Classifications were excluded if their scope was limited to a single mobility device domain. The six classifications were analyzed according to a common framework: (1) purpose, (2) completeness, (3) granularity, and (4) research applications. Although each classification addresses three principal mobility device domains (ambulation aids, manual wheelchairs, and powered mobility devices), the analysis revealed a range of detail with which each domain is described. Some classifications were hampered by their use of unclear idiosyncratic terminology, whereas others conflated multiple device features within device categories. The analysis suggests that existing classifications do not fully meet the needs of assistive technology outcomes researchers. Creation of a common taxonomy of mobility devices is needed to serve the needs of the assistive technology outcomes research field.

Repeat dual-energy X-ray absorptiometry (DXA) resulting from reminder letters for women with a baseline abnormal DXA.

The objective was to assess the effects of reminder letters on women returning for repeat bone density. We queried our clinical data repository to identify all women undergoing dual-energy X-ray absorptiometry (DXA) during the entire 2003 calendar year. Women with abnormal DXAs were entered into a database for reminder letters. The electronic medical record was then reviewed for the presence of the reminder letter and whether any repeat DXA scan was done. Approximately half of the women returned for repeat DXA of this group, approximately one-third were improved, one-third deteriorated, and the remaining were unchanged. We suggest a clinical benchmark of a minimum of 50% of women with abnormal bone density returning for repeat DXA on the same machine at a DXA imaging center should be a quality improvement goal. Further research into exploring why patients do not return for serial DXA and the impact of reminder letters on improving treatment outcomes should be conducted.

5-fluorouracil-induced coronary vasospasm.

BACKGROUND: Cardiotoxicity is a rare but well-documented adverse effect of 5-fluorouracil (5-FU). The underlying cause of this side effect of 5-FU is uncertain. METHODS: We present a case report of a 63-year-old man treated for metastatic colon cancer who experienced chest pain while being treated with the FOLFIRI regimen. This case report documents coronary artery spasm on catheterization observed with the continuous infusion of 5-FU. RESULTS: Cardiac catheterization obtained within 36 hours of the onset of chest pain revealed marked coronary vasospasm in the obtuse marginal coronary artery and a right coronary artery with a critical obstructive atherosclerotic plaque. Electrocardiogram revealed the myocardium area associated with the event was diffuse rather than localized to the right coronary artery. CONCLUSIONS: This observation supports the vasospastic hypothesis for 5-FU-induced angina. Although rare, this type of cardiotoxicity with 5-FU is a potentially lethal side effect. Therapy with 5-FU should be discontinued and patients should be promptly treated.