Calciphylaxis and Intractable Pain in a Veteran with Psychological Trauma History.

Guidelines are lacking for patients with calciphylaxis on renal replacement therapy, often leading to difficulty optimally treating these patients. A 60-year-old male veteran receiving hemodialysis presented with calciphylaxis of the left lower extremity and intractable pain. His condition was complicated by chronic back pain, long-term opioid therapy, and psychological trauma history. He was ultimately transferred to a calciphylaxis treatment center but was unable to tolerate further treatments due to sepsis and hemodynamic instability. He was transitioned to comfort measures and died in the hospital. Addressing complicated pain physiologies and complex trauma is challenging even in well-resourced tertiary medical centers. Despite the availability of calciphylaxis therapies and trauma-informed care, there remains a high rate of suffering and mortality in this patient population. There is much work to be done in this cohort, particularly when considering the implications of past traumatic experiences on health care engagement and pain management.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness.

BACKGROUND: The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness. METHODS: We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival. RESULTS: The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups. CONCLUSIONS: A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Pharmacologic Pain Management: What Radiation Oncologists Should Know.

Individuals with cancer experience a host of symptoms, especially when the malignancy is advanced. Pain occurs from the cancer itself or related treatments. Undertreated pain contributes to patient suffering and lack of engagement in cancer-directed therapies. Adequate pain management includes thorough assessment; treatment by radiotherapists or anesthesia pain specialists; anti-inflammatory medications, oral or intravenous opioid analgesics, and topical agents; and attention to the emotional and functional effects of pain, which may involve social workers, psychologists, speech therapists, nutritionists, physiatrists and palliative medicine providers. This review discusses typical pain syndromes arising in cancer patients undergoing radiotherapy and provides concrete recommendations for pain assessment and pharmacologic treatment.

Challenges for Patients Dying of Heart Failure and Cancer.

BACKGROUND: Hospice and palliative care were originally implemented for patients dying of cancer, both of which continue to be underused in patients with heart failure (HF). The objective of this study was to understand the unique challenges faced by patients dying of HF compared with cancer. METHODS: We assessed differences in demographics, health status, and financial burden between patients dying of HF and cancer from the Health and Retirement Study. RESULTS: The analysis included 3203 individuals who died of cancer and 3555 individuals who died of HF between 1994 and 2014. Compared with patients dying of cancer, patients dying of HF were older (80 years versus 76 years), had poorer self-reported health, and had greater difficulty with all activities of daily living while receiving less informal help. Their death was far more likely to be considered unexpected (39% versus 70%) and they were much more likely to have died without warning or within 1 to 2 hours (20% versus 1%). They were more likely to die in a hospital or nursing home than at home or in hospice. Both groups faced similarly high total healthcare out-of-pockets costs ($9988 versus $9595, P=0.6) though patients dying of HF had less wealth ($29 895 versus $39 008), thereby experiencing greater financial burden. CONCLUSIONS: Compared with patients dying of cancer, those dying from HF are older, have greater difficulty with activities of daily living, are more likely to die suddenly, in a hospital or nursing home rather than home or hospice, and had worse financial burden.

Complexities of Corona Virus Disease-19: The Role of Palliative Care at a Veterans Affairs Hospital.

The Corona Virus Disease-19 (COVID-19) pandemic accentuated the need for delivery of quality palliative care. We share the experience of our acute care hospital palliative care team in caring for veteran patients who died from COVID-19 and provide recommendations for palliative care teams caring for older adult populations. We conducted a retrospective chart review on 33 patients to gather characteristics data and delineate palliative care team involvement in their clinical courses. Our palliative care team participated in the care of 87.9% of patients who died from COVID-19. They were medically and psychosocially complex with 75.8% carrying at least four medical comorbidities, 87.8% presenting from an institutional facility, and 39.4% diagnosed with at least one psychiatric condition. Our results emphasize the impact of this pandemic on vulnerable populations and highlight the benefits of palliative care for support of patients, their loved ones, and the clinical teams caring for them.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Jewish Patients.

Judaism, one of the world's oldest religions, claims an estimated 14.3 million members worldwide. There is great diversity in terms of identity, practice, and belief among people who identify as Jewish. As of 2017, 40% of the global Jewish community resided in the United States, making it essential for palliative care clinicians to understand religious and cultural issues related to their serious illness care. In this article, we will discuss 10 important concepts relevant to the inpatient care, advance care planning, and bereavement needs of Jewish patients and families.

Top Ten Tips Palliative Care Clinicians Should Know About Opioid Use Disorder.

Since the prevalence of substance use disorders, and opioid use disorder (OUD) specifically, remains high and represents a public health crisis, it is critical that palliative care (PC) providers have a broad understanding of this class of chronic, yet treatable, diseases. Conceptualizing stigma associated with OUD, treatment modalities available, and educational opportunities are key factors in providing patient-centered care. A solid foundation of knowledge about OUD in the setting of serious illness is also crucial as PC providers often recommend or prescribe opioids for symptom management in patients who also have OUD. Furthermore, the PC interdisciplinary team is particularly well poised to care for patients suffering from OUD due to the inherently holistic approach already present in the specialty of PC. This article offers PC teams a framework for understanding the diagnosis and treatment of OUD, methods for performing risk stratification and monitoring, and an overview of opportunities to enhance our care of PC patients with OUD.

Managing Opioid Use Disorder in the Setting of a Terminal Disease: Opportunities and Challenges.

Opioids have long been a mainstay of symptom management in palliative care (PC), allowing patients with terminal illnesses to have an improved quality of life. Unfortunately, these same medications have contributed to the explosion of the opioid epidemic. This article explores the case of a patient with opioid use disorder (OUD) and pancreatic cancer. We share our experience of managing his symptoms and treating OUD in the setting of an outpatient PC clinic. We explore the challenges and joys of this case while reflecting on the need for more research investigating best practices for individuals where opioids serve as both a pain reliever and contributor to further suffering from their OUD.

Rally the Troops: Interdisciplinary Response to a Veteran Who Attempted Suicide on a Veterans Affairs Hospice Unit.

Requests for hastened death and suicidal ideation may be more prevalent in populations approaching the end of life. Often these wishes and thoughts occur in the context of concurrent psychiatric disorders and emotional suffering. We discuss the case of a veteran with terminal lung cancer and comorbid psychiatric illness who attempted suicide while under the care of an inpatient interdisciplinary hospice team and describe our team's response to this suicide attempt. We review risk factors for suicidality at end of life, challenges of distinguishing desire for hastened death from suicidality, and the ethics of resuscitation of a dying patient after a suicide attempt.

Improving Palliative Care Team Meetings: Structure, Inclusion, and "Team Care".

Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients' plans of care, thus positively impacting team members' ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting "toolkit."

Spiritual distress of military veterans at the end of life.

OBJECTIVE: Although combat experiences can have a profound impact on individuals' spirituality, there is a dearth of research in this area. Our recent study indicates that one unique spiritual need of veterans who are at the end of life is to resolve distress caused by combat-related events that conflict with their personal beliefs. This study sought to gain an understanding of chaplains' perspectives on this type of spiritual need, as well as the spiritual care that chaplains provide to help veterans ease this distress. METHOD: We individually interviewed five chaplains who have provided spiritual care to veterans at the end of life in a Veterans Administration hospital. The interviews were recorded, transcribed, and analyzed based on "grounded theory." RESULTS: Chaplains reported that they frequently encounter veterans at the end of life who are still suffering from thoughts or images of events that occurred during their military career. Although some veterans are hesitant to discuss their experiences, chaplains reported that they have had some success with helping the veterans to open up. Additionally, chaplains reported using both religious (e.g., confessing sins) and nonreligious approaches (e.g., recording military experience) to help veterans to heal. SIGNIFICANCE OF RESULTS: Our pilot study provides some insight into the spiritual distress that many military veterans may be experiencing, as well as methods that a chaplain can employ to help these veterans. Further studies are needed to confirm our findings and to examine the value of integrating the chaplain service into mental health care for veterans.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity.

INTRODUCTION: Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes. AREAS COVERED: A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared. EXPERT OPINION: Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals.

INTRODUCTION: Older adults are generally considered to be at greater risk for medication non-adherence due to factors such as medication complexity, side effects, cost, and cognitive decline. However, this generalization may not apply to older adults with human immunodeficiency virus (HIV). Regardless of age, suboptimal adherence to antiretroviral therapy (ART) can lead to increased viral load, immunosuppression, drug-resistant viral strains, co-morbidities, and opportunistic infections. Understanding trends of adherence to ART among older adults is critical, especially as the population of people living with HIV grows older. OBJECTIVES: The purpose of this systematic review and meta-analysis is to determine if older individuals with HIV are less likely to be non-adherent to antiretroviral therapy than younger individuals with HIV. DESIGN: A systematic search in PubMed, Embase, and PsycINFO was conducted to identify peer-reviewed articles evaluating adherence to ART in older adults. Two independent reviewers screened abstracts, applied inclusion criteria, and appraised study quality. The bibliographies of qualifying studies were searched. Data were abstracted from studies by two independent authors. Meta-analyses were conducted, and adherence levels were reported as the relative risk of non-adherence in older individuals compared to younger individuals. RESULTS: The systematic search yielded 1,848 abstracts. Twelve studies met full inclusion criteria. The overall meta-analysis found that older age reduced risk for nonadherence by 27 % (relative risk (RR) 0.72, 95 % confidence interval (CI) 0.64­0.82). Studies assessing both short-term and long-term adherence demonstrated a significant reduction in non-adherence among older patients (RR 0.75, 95 % CI 0.64­0.87 and RR 0.65, 95 % CI 0.50­0.85, respectively). CONCLUSIONS: Older adults with HIV have a reduced risk for non-adherence to ART than their younger counterparts. Future studies should seek to elucidate contributing factors of adherence among older individuals with HIV.

End-of-life spiritual care at a VA medical center: chaplains' perspectives.

OBJECTIVE: Spiritual care is an essential component of quality palliative care. Recognizing the importance, the Department of Veterans Affairs (VA) mandates the inclusion of chaplains in a palliative care consult team (PCCT). The purpose of this study is to explain the process and content of spiritual care provided in a VA Medical Center from chaplains' perspectives. METHOD: Five Christian chaplains who provide care to patients at end of life were interviewed. Each interview was recorded and transcribed. Analysis based on the grounded theory was used to identify themes from each interview question. RESULTS: The PCCT in this study appeared to have a strong referral and communication system in which every palliative care patient was seen by a chaplain and the care plan was discussed with an interdisciplinary team. Chaplains reported providing a range of services, which addressed religious, spiritual, emotional, family, and illness concerns. Chaplains were aware of the unique spiritual needs of veterans, including working through guilt for killing in war and requiring forgiveness. Chaplains' ideas for improvement of spiritual care services included increasing time to provide care, providing bereavement care and support to families, and adding chaplains with different religious backgrounds. Chaplains reported how their own spirituality influenced the care they provided. SIGNIFICANCE OF RESULTS: Spiritual care in the VA can include a range of services and should consider the unique needs of the veteran population. Future studies can build upon our findings from chaplains to learn about the perspectives of patients, family, and other healthcare providers of spiritual care. This information would allow identification of strengths of current spiritual care practices and areas for care improvement, and ultimately could improve the well-being of patients at the end of life.

Spiritual needs and spiritual care for veterans at end of life and their families.

Spiritual care is an important domain of palliative care programs across the country and in the Veterans Affairs (VA) Healthcare System specifically. This qualitative study assessed the spiritual needs, spiritual care received, and satisfaction with spiritual care of both Veterans at the end of life and their families. Seventeen Veterans and 9 family members participated. They expressed a wide range of spiritual needs, including a wish of Veterans to have a better understanding of traumatic events that occurred during their combat experience. Some Veterans reported military experience enhanced their spirituality. Generally, respondents reported satisfaction with VA spiritual care, but indicated that Veterans may benefit from greater access to VA chaplains and explicit discussion of the impact of their military experience on their spirituality.

Patient-physician boundaries in palliative care training: a case study and discussion.

Abstract The subject of patient-physician boundaries has been most extensively explored in the psychiatric literature, but to date, little has been published about this concept within the realm of palliative care. Some palliative care physicians may be particularly susceptible to boundary crossings due to the intensity and intimacy of the bonds that form with patients at the end-of-life. We illustrate the concept of boundary crossings and violations in palliative care using the case of a palliative care trainee who experiences difficulties in maintaining boundaries with a dying patient. We discuss the nature of the patient-physician relationship using role theory and discuss how the formation of dual roles can be detrimental to the patient-physician relationship. Finally, we explore why palliative care practitioners and trainees are particularly vulnerable to crossing boundaries and how to recognize and manage these crossings when they occur.

Ovarian carcinoma with thyroid metastases causing clinical hypothyroidism: a case report.

BACKGROUND: Ovarian cancer is known to metastasize to the thyroid gland. Despite an incidence of ovarian metastasis to the thyroid of 3-15%, clinical hypothyroidism resulting from such metastasis has not yet been reported. We present a case of metastatic ovarian cancer to the thyroid resulting in clinical hypothyroidism. CASE: A 55-year-old woman with recurrent papillary adenocarcinoma of the ovary presented with fatigue, abdominal distention, lymphedema, and depression. Thyroid stimulating hormone was markedly elevated, and thyroid biopsy demonstrated bilateral metastatic ovarian carcinoma. CONCLUSION: Although uncommon, metastatic disease to the thyroid should be considered when evaluating a patient with advanced ovarian cancer and clinical hypothyroidism.