Effect of Palliative Care-Led Meetings for Families of Patients with Chronic Critical Illness

Newswise, July 8, 2016 — Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms, according to a study appearing in the July 5 issue of JAMA.

Patients are considered to have developed chronic critical illness when they experience acute illness requiring prolonged mechanical ventilation or other life-sustaining therapies but neither recover nor die within days to weeks.

It is estimated that chronic critical illness affected 380,000 patients in the United States in 2009. Family members of patients in the intensive care unit (ICU) experience emotional distress including anxiety, depression, and posttraumatic stress disorder (PTSD).

Palliative care specialists are trained to provide emotional support, share information, and engage patients and surrogate decision makers in discussions of patient values and goals of care.

Shannon S. Carson, M.D., of the University of North Carolina School of Medicine, Chapel Hill, N.C., Judith E. Nelson, M.D., J.D., of the Memorial Sloan Kettering Cancer Center, New York, and colleagues randomly assigned adult patients requiring 7 days of mechanical ventilation and their family surrogate decision makers to at least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention), or provision of an informational brochure and routine family meetings conducted by ICU teams (control).

There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. The study was conducted at 4 medical ICUs.

Among 365 family surrogate decision makers, 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group.

Posttraumatic stress disorder symptoms were higher in the intervention group compared with the control group. There was no difference between groups regarding the discussion of patient preferences. The median number of hospital days for patients in the intervention vs the control group and 90-day survival were not significantly different.

Potential explanations for this lack of benefit may relate to the high perceptions of quality of communication, emotional support, and family satisfaction in the usual care control.

“When informational support provided by the primary team is sufficient, additional focus on prognosis may not help and could further upset a distressed family, even when emotional support is concurrently provided,” the authors write.

“Alternatively, the intervention may have been insufficient to overcome the high levels of family stress associated with having a relative with chronic critical illness.”

“These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.”

Palliative Care Offers Greater Cost Savings for Cancer Patients with Multiple Chronic Conditions

Newswise, January 6, 2016--Patients with incurable cancer and numerous other serious health conditions who consulted with a palliative care team within two days of hospitalization had significant savings in hospital costs, according to a new study led by researchers at the Icahn School of Medicine at Mount Sinai.

Published in the January issue of the journal Health Affairs, the study also determined that the higher number of serious coexisting conditions patients had, the greater reduction in direct hospital costs.

While previous studies have shown the link between palliative care and lower costs, this is the first study to examine whether the effect of palliative care consultation varies by the number of co-existing chronic conditions.

Researchers compared a treatment group of advanced cancer patients with numerous serious health conditions (also known as comorbidities) from six hospitals who were seen by a palliative care team with a separate group who received usual care.

Findings indicated that patients from the treatment group on average had a 22 percent reduction in costs compared to the group that did not receive palliative consultation.

Data showed that patients with the highest number of comorbidities had up to a 32 percent reduction in costs. The study’s findings suggest that early palliative consultations with the sickest patients may decrease unwanted aggressive end-of-life care, as well as shorten length of stays in hospital. 

Palliative care is a team-based specialty (incorporating medicine, nursing, social work and chaplaincy) focused on improving quality of life for people with serious illnesses by adding a layer of support for patients, their families, and health care providers.

It is provided in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies.

Programs using palliative care consultation teams have rapidly expanded in recent years. Today, over 90 percent of medium-size to large U.S. hospitals now have palliative care teams.

“We already know that coordinated, patient-centered palliative care improves care quality, enhances survival, and reduces costs for persons with cancer,” said R. Sean Morrison, MD, Director of the National Palliative Care Research Center and Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai and lead author of the study.

“Our latest research now shows the strong association between cost and the number of co-occurring conditions. Among patients with advanced cancer and other serious illnesses, aggressive treatments are often inconsistent with patients’ wishes and are associated with worse quality of life compared to other treatments. It is imperative that policymakers act to expand access to palliative care.”

Patients with multimorbidities account for a high proportion of U.S. health care spending. They also comprise two-thirds of Medicare beneficiaries and account for almost half of the program’s total spending.

According to the Centers for Medicare and Medicaid Services (CMS), over the next decade, annual Medicare expenditures will increase by 98 percent and total annual national health spending will grow by 76 percent, reaching $5.4 trillion.

Increasing access to palliative care during hospitalization for patients with advanced cancer and multiple chronic conditions could both improve care and help curb the growth of health care spending.

“The fact that we found greater cost savings for cancer patients with more comorbidities than for those with fewer comorbidities raises the question of whether similar results would be observed in patients with other serious illnesses and multimorbidity,” said Professor Peter May of Trinity College Dublin and a former visiting research fellow in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai and co-author of the study.

“Future research is also needed to determine when in the course of illness palliative care is most cost-effective.”

The study was supported by the National Cancer Institute (NCI) and the National Institute of Nursing Research. Additional collaborators include researchers from Johns Hopkins University, Trinity College Dublin, Virginia Commonwealth University and James J. Peters VA Medical Center.

About the Mount Sinai Health System


The Mount Sinai Health System is an integrated health system committed to providing distinguished care, conducting transformative research, and advancing biomedical education. Structured around seven hospital campuses and a single medical school, the Health System has an extensive ambulatory network and a range of inpatient and outpatient services—from community-based facilities to tertiary and quaternary care.

The System includes approximately 6,100 primary and specialty care physicians; 12 joint-venture ambulatory surgery centers; more than 140 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. Physicians are affiliated with the renowned Icahn School of Medicine at Mount Sinai, which is ranked among the highest in the nation in National Institutes of Health funding per investigator. The Mount Sinai Hospital is ranked as one of the nation’s top 10 hospitals in Geriatrics, Cardiology/Heart Surgery, and Gastroenterology, and is in the top 25 in five other specialties in the 2015-2016 “Best Hospitals” issue of U.S. News & World Report. Mount Sinai’s Kravis Children’s Hospital also is ranked in seven out of ten pediatric specialties by U.S. News & World Report. The New York Eye and Ear Infirmary of Mount Sinai is ranked 11th nationally for Ophthalmology, while Mount Sinai Beth Israel is ranked regionally.

For more information, visit www.mountsinai.org or find Mount Sinai on Facebook, Twitter and YouTube.

Best And Worst States Providing Access To Palliative Care

State-by-State Report Card shows improvement, but persistent gaps in access for the seriously ill remain

WASHINGTON, Oct. 12, 2015 /PRNewswire-USNewswire/ -- America's Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals, released  on Capitol Hill and in the Journal of Palliative Medicine, demonstrates that access to palliative care remains highly variable and depends more upon accidents of geography and hospital ownership than it does upon the needs of patients with serious illness.

Millions of seriously ill Americans and their families living in the south of the United States, as well as in Alaska,Kansas, New Mexico and Wyoming, still have inadequate access to palliative care teams. 

The report was conducted by the Center to Advance Palliative Care (CAPC) and National Palliative Care Research Center (NPCRC).

Palliative care is a new medical specialty focused on maximizing quality of life during serious illness through relief of the pain, symptoms and stress that patients and their families commonly experience. 

It is delivered at the same time as all other appropriate treatments. Palliative care leads to better quality of care, longer life, and is appropriate at any age and any stage of a serious illness.

Key findings on the growth in access to hospital palliative care teams across the fifty states include:

• Overall, the southern U.S states received a grade of C (60% or fewer hospitals have palliative care teams) as compared to As and Bs (60% or more hospitals) for all other regions.
• States receiving a D grade (40% or less of hospitals having palliative care) were Alabama, Alaska, Arkansas,Mississippi, New Mexico, Oklahoma and Wyoming.
• Only 23% of for-profit hospitals have palliative care. Not-for-profit hospitals are 7 times more likely to have a palliative care team than for-profits. 
• In a sign of progress since 2008, 17 states received a grade of A (up from 3 in the 2008 report and 7 in the 2011 report). They are: Connecticut, Maryland, Massachusetts, Minnesota, Montana, Nebraska, Nevada,New Hampshire, New Jersey, Ohio, Oregon, Rhode Island, South Dakota, Utah, Vermont, Washington andWisconsin.
• 90% hospitals with 300 beds or more have palliative care teams.
• 90% of hospitals operated by the Catholic Church have palliative care.
• 78% of Medicare patients died near a hospital that had a palliative care team, suggesting that access is improving for this patient population.
• 96% of teaching hospitals now have palliative care teams, increasing the likelihood that the next generation of clinicians will receive training.

"It is our hope that this report card focuses attention on lingering gaps in access to palliative care in our nation's hospitals," said Diane E. Meier, MD, director of the Center to Advance Palliative Care. 

"Palliative care, like any core medical service such as ICU's or emergency departments, should be available in all U.S. hospitals."

R. Sean Morrison, MD, director of the National Palliative Care Research Center added, "The dramatic growth in the number of hospitals with palliative care teams is encouraging.  Whereas we need to continue to assist hospitals in C and D states, it is important to focus attention on ensuring that all seriously ill patients actually receive it in a timely fashion, and that access moves beyond hospitals to other sites of care." 

Barriers to palliative care access remain in three key areas: a workforce that is too small to meet current and projected demand; an underdeveloped knowledge base to provide the highest quality of care and a lack of payment models linked to quality measures.

Center to Advance Palliative Care
The Center to Advance Palliative Care (CAPC) is a national organization dedicated to increasing the availability of palliative care services for people facing serious illness. www.capc.org, getpalliativecare.org,https://reportcard.capc.org.

The National Palliative Care Research Center
The National Palliative Care Research Center (NPCRC) is dedicated to advancing palliative care research capacity in the United States. www.npcrc.org 

CAPC and NPCRC are part of the Icahn School of Medicine at Mount Sinai, located in New York City.

The report card was supported in part by grants from the American Cancer Society, the Cambia Health Foundation and the National Institute on Aging.

Saint Louis University Launches Missouri’s First Palliative Care Fellowship

SLUCare Geriatrician: ‘Treat the Whole Person’

Newswise, September 28, 2015 — ST. LOUIS – As the number of older adults climbs at a faster pace in Missouri than nationally, Saint Louis University has started the first hospice and palliative medicine fellowship program in the state.

Palliative care physicians care for patients who need active treatment to manage a serious disease as well as those at the end of their lives. Many older adults receive palliative care, and Medicare recently announced plans to reimburse physicians for talking with their patients about end of life issues.

SLUCare Physician Group geriatrician Dulce Cruz Oliver, M.D., who is board-certified in hospice and palliative medicine and an assistant professor of internal medicine at SLU School of Medicine, directs of SLU’s new fellowship, which began in July.

“During the past five years that I have been an assistant professor of internal medicine at SLU, I’ve found that the more I worked with elders, the more passionate I have become about caring for those who are seriously ill, especially patients who are close to the end of their lives,” she said. “I love what we do and appreciate the opportunity to talk with our patients and really help them.”

The Hospice and Palliative Medicine Fellowship will train one physician this year in the subspecialty that cares for those who have chronic, life-changing illnesses like cancer, congestive heart failure or chronic obstructive pulmonary disease. Fourth year medical school students and residents also will receive training through a palliative care educational elective that is related to the program, Cruz added.

“Palliative care helps a patient adapt to all of the changes that come with a specific disease,” Cruz says. “This field creates an awareness of how important it is for doctors to treat the whole patient – not just his or her medical symptoms – to talk with and listen to patients.

“We need to hear from patients about their expectations and goals, and spend time with them to help them understand what is going on. For instance, we might explain to a patient how to complete an advanced directive or help a patient who has COPD deal with shortness of breath without taking a traditional medicine. We might help someone who is no longer able to work make that transition.”

In addition to the Hospice and Palliative Medicine Fellowship, Cruz has started the Supportive Care Clinic, a pilot program held twice a month for Saint Louis University Cancer Center patients who are referred by their physicians. “It’s not only a physician who provides the care, you need a team that might include a chaplain and social worker,” says Cruz, who is part of the treatment team.

Through specialized sessions, patients learn to experience their best possible quality of life as they deal with the emotional and psychological challenges presented by a cancer diagnosis. For example, they might explore ways to manage their pain that don’t involve taking drugs or strategies to cope with the anxiety that can accompany being diagnosed and treated for cancer. Cruz sees the service as an important addition to medical treatment, and is encouraged by how well the pilot program is being received.

Cruz’s interest in palliative care complements her medical specialty of geriatrics. As a little girl in Puerto Rico, Cruz saw her grandmother caring for members of their village who became ill, which inspired her to become a physician who takes the time to listen to the older adults she treats.

“My grandmother was a santigüera – a healer for her village in Lares, Puerto Rico. People would come to her with medical problems like joint pain or illnesses like shingles, and she prayed on them and gave them a natural remedy. I saw the impact of complementary medicine on our friends and family who looked to my grandmother for loving care.”

During her internal medicine residency, Cruz conducted research on palliative care, becoming intellectually drawn to the area of medicine. But after her medical training, her connection to the field became deeply personal as she watched a close friend battle ovarian cancer.

“The many difficulties and challenges she endured caused her and all of us around her to suffer. All of the things she went through would have been better if there had been a good palliative care program in place. I’m committed to training others to change the way palliative care is delivered in this city,” she said.

Cruz recently was selected as one of only 10 physicians or nurses in the nation into Cambia Health Foundation’sSojourns Scholar Leadership Program, which cultivates the next generation of health care providers to advance the field of palliative care.

The Sojourns Scholar program will support Cruz’s work at the Hospice and Palliative Medicine Fellowship and Supportive Care Center, in addition to funding professional development. Cruz will received mentoring in patient care from the Center to Advance Palliative Care, work on a research project at the National Institute of Aging and attend the Harvard Macy Institute to learn how to use new technologies to enhance the quality of her teaching.

Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the first medical degree west of the Mississippi River. The school educates physicians and biomedical scientists, conducts medical research, and provides health care on a local, national and international level. Research at the school seeks new cures and treatments in five key areas: infectious disease, liver disease, cancer, heart/lung disease, and aging and brain disorders.