Journal of pain and symptom management最新文献

{"title":"Continuation of Potentially Inappropriate Life-Sustaining Therapies: Provider Perspectives","authors":"Rebekka DePew MD ,&nbsp;Kemberlee Bonnet MA ,&nbsp;David Schlundt PhD ,&nbsp;Jessica Turnbull MD, MA ,&nbsp;Rebecca Propper MD","doi":"10.1016/j.jpainsymman.2025.04.011","DOIUrl":"10.1016/j.jpainsymman.2025.04.011","url":null,"abstract":"<div><h3>Background</h3><div>Prior work examines provider perspectives on withholding potentially inappropriate life-sustaining treatments over family objections; however, data are limited regarding how physicians approach situations in which they are considering withholding or withdrawing life-sustaining therapies against the wishes of the patient’s family.</div></div><div><h3>Measures</h3><div>This study sought to better understand the way in which pediatric critical care clinicians navigate situations in which families request life-sustaining therapies that the team feels may be inappropriate.</div></div><div><h3>Outcomes</h3><div>We conducted a series of semi-structured group interviews with pediatric critical care faculty and used these data to create a case-based, ten-question ethical dilemma survey, which was disseminated nationally to pediatric intensivists. This paper explores participant responses to survey question three, which presented a case in which family requests continuation of ventilatory/nutritional support after severe traumatic brain injury with minimal recovery potential.</div></div><div><h3>Outcomes</h3><div>Most participants reported that they would offer the requested interventions; however, there was substantial variation among participants regarding the best next steps. Participants who chose to submit free-text responses described thoughtfully attempting to balance avoiding prolongation of suffering and respecting parents’ roles as decision-makers for their child.</div></div><div><h3>Conclusions/Lessons Learned</h3><div>The variation between participants in their approach to this ethical dilemma underscores its difficulty, as well as the importance of institutional support structures (e.g. ethics, legal, risk management, palliative care). In a healthcare system with limited resources to support families taking care of critically ill and technology-dependent children, our study underscores a need for training, practice, and institutional support for physicians assisting families in navigating these decisions.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages e137-e143"},"PeriodicalIF":3.2,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143968312","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is it Time to Rethink Pediatric Palliative Care Staffing to Optimize Access?","authors":"Amy S. Porter MD, PhD ,&nbsp;Chelsea Heneghan CPNP, MSN ,&nbsp;Jennifer M. Snaman MD, MS","doi":"10.1016/j.jpainsymman.2025.04.010","DOIUrl":"10.1016/j.jpainsymman.2025.04.010","url":null,"abstract":"","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages e119-e120"},"PeriodicalIF":3.2,"publicationDate":"2025-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144014958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Low Dose Olanzapine for Cases of Refractory Nausea and Vomiting and Vertigo After Cerebellar Stroke","authors":"Eric Altschuler MD, PhD ,&nbsp;Adrien Golocovsky MD ,&nbsp;James Guider MD ,&nbsp;Isaac Kim DO ,&nbsp;Ivani Proaño DO ,&nbsp;Manuela Morales-Rodriguez APN ,&nbsp;Neil Jasey MD ,&nbsp;Radhika Bapineedu MD","doi":"10.1016/j.jpainsymman.2025.04.006","DOIUrl":"10.1016/j.jpainsymman.2025.04.006","url":null,"abstract":"","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 1","pages":"Pages e90-e92"},"PeriodicalIF":3.2,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143968316","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Characterizing the Documentation of Time-Limited Trials in Goals of Care Notes","authors":"Gina M. Piscitello MD, MS ,&nbsp;Robert M. Arnold MD ,&nbsp;Jane O. Schell MD, MHS ,&nbsp;Jacqueline M. Kruser MD, MS","doi":"10.1016/j.jpainsymman.2025.04.007","DOIUrl":"10.1016/j.jpainsymman.2025.04.007","url":null,"abstract":"<div><h3>Context</h3><div>Time-limited trials (TLTs) are a collaborative plan among clinicians, patients, and surrogates to use life-sustaining therapy for a defined duration, after which the response to therapy informs the decision to either continue care focused on recovery or transition to comfort-focused care.</div></div><div><h3>Objectives</h3><div>To evaluate 1) how often goals of care (GOC) notes document TLT use; 2) what patient and clinician characteristics are associated with documented TLTs; and 3) how TLTs are described in GOC documentation.</div></div><div><h3>Methods</h3><div>We conducted a retrospective cross-sectional study of documented standardized GOC template notes for seriously ill hospitalized adult patients across 21-hospitals between 2021 and 2023. We evaluated notes using descriptive statistics paired with qualitative, directed content analysis.</div></div><div><h3>Results</h3><div>Of 5475 GOC-template notes, we found reference to a TLT in 1% (<em>n</em> = 69/5475). Patients with TLT documentation were younger (72 vs 76 years, <em>P</em> = 0.0221), more likely to be self-pay or uninsured (7% vs. 2%, <em>P</em> = 0.0309), more likely to die in the hospital (54% vs. 27%, <em>P</em> &lt; 0.0001) or discharge to a long-term acute care hospital (15% vs. 1%, <em>P</em> &lt; 0.0001), when compared to patients with no such documentation. Notes with TLT documentation were more likely to document patient prognosis (94% vs. 79%, <em>P</em> = 0.0009) and less likely to document an accompanying change in patient code status (22% vs. 36%, <em>P</em> = 0.0117).</div></div><div><h3>Conclusions</h3><div>TLTs are rarely documented within a standardized GOC note for seriously ill patients. Future research is needed to identify and address reasons for low documentation of TLTs in the EHR.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages e129-e136"},"PeriodicalIF":3.2,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143987023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Screening for Depression in Palliative Care","authors":"Mellar P Davis MD, FCCP, FAAHPM","doi":"10.1016/j.jpainsymman.2025.04.009","DOIUrl":"10.1016/j.jpainsymman.2025.04.009","url":null,"abstract":"","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 1","pages":"Pages e93-e94"},"PeriodicalIF":3.2,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144018939","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early Specialist Palliative Care in Patients with Metastatic Cancer: A Population-Based Cohort Study","authors":"Ling Guo MD, MPH ,&nbsp;Thomas W. LeBlanc MD, MA, MHS ,&nbsp;Cardinale B. Smith MD, PhD ,&nbsp;R. Sean Morrison MD ,&nbsp;May Hua MD, MS","doi":"10.1016/j.jpainsymman.2025.04.005","DOIUrl":"10.1016/j.jpainsymman.2025.04.005","url":null,"abstract":"<div><h3>Context</h3><div>Although early integration of specialist palliative care (PC) is recommended for patients with advanced cancer, how frequently these guidelines are followed is unknown.</div></div><div><h3>Objective</h3><div>To examine use of early PC in real-world settings.</div></div><div><h3>Methods</h3><div>Retrospective cohort study of patients with a first diagnosis of metastatic cancer who received care in U.S. hospitals with PC programs that participated in the National Palliative Care Registry in 2018–2019. The primary outcome was the proportion of early specialist PC initiation (within eight weeks of a first metastatic cancer diagnosis) overall and after stratification by cancer type. Patient, hospital and PC program characteristics were compared between patients who received early PC, late PC, and no PC.</div></div><div><h3>Results</h3><div>Of 171,224 patients, 14.1% received PC during the study period. Only 8.0% of patients received early PC. Proportions of early PC were highest for patients with lung cancer, and lowest for patients with breast cancer (12.0% vs. 4.3%). Patients who received early PC had more comorbidities, diagnoses for symptoms or psychiatric conditions, and complications of cancer, and were more likely to have had a serious hospitalization in the prior 12 months. Hospital and program characteristics were not substantially different between patients who did and did not receive early specialist PC.</div></div><div><h3>Conclusion</h3><div>A low proportion of patients with metastatic cancer received early specialist PC, demonstrating a significant gap in guideline-concordant delivery of specialist PC. Patients who received early PC were substantially different from those who did not, suggesting that its use is targeted to patients with specific characteristics.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages 140-148.e2"},"PeriodicalIF":3.2,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143977007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Circadian Rhythm in End-Of-Life Delirium: A Secondary Analysis of Two Randomized Controlled Trials","authors":"Sonal Admane MD, MPH ,&nbsp;Sarah Pasyar MS ,&nbsp;Roland Bassett Jr. MS ,&nbsp;Eduardo Bruera MD ,&nbsp;David Hui MD, MSc","doi":"10.1016/j.jpainsymman.2025.04.003","DOIUrl":"10.1016/j.jpainsymman.2025.04.003","url":null,"abstract":"<div><h3>Context</h3><div>The circadian pattern of restlessness in end-of-life delirium is understudied and poorly understood.</div></div><div><h3>Objective</h3><div>To examine the timing of breakthrough restlessness in patients with advanced cancer and end-of-life delirium admitted to an acute palliative care unit.</div></div><div><h3>Methods</h3><div>This is a secondary analysis of two randomized clinical trials that examined the effect of lorazepam (MAD trial) and neuroleptics (CHAD trial) in end-of-life delirium. In this study we examined the frequency of restlessness in 8-hour intervals (7 AM–3 PM, 3–11 PM, 11 PM–7 AM). Breakthrough restlessness was measured based on 1) rescue medications (neuroleptics or benzodiazepines) administered for breakthrough restlessness and 2) a Richmond Agitation-Sedation Scale (RASS) score ≥+1 (collected every 2–4 hours).</div></div><div><h3>Results</h3><div>This study included 128 patients (58 from MAD trial, 70 from CHAD trial); the mean age (SD) was 64 (12.5), and 57 (44.5%) were women. We found that 3–11 PM was significantly associated with greater rescue medication use in univariate analysis for both trials (MAD: Estimate: 0.35, 95% CI: 0.23–0.48, <em>P</em> &lt; 0.001; CHAD: Estimate: 0.1, 95% CI: 0.07–0.12, <em>P</em> &lt; 0.001). This association remained significant in multivariate analysis for CHAD (Estimate: 0.1, 95% CI: 0.07–0.12, <em>P</em> &lt; 0.001). About 3–11 PM was also associated with greater episodes of RASS ≥+1 in MAD in univariate and multivariate analysis (Estimate:0.31, 95 % CI: 0.21–0.42, <em>P</em> &lt; 0.001).</div></div><div><h3>Conclusion</h3><div>Delirious patients were more restless between 3 PM and 11 PM. This observation of “sundowning” may help clinicians to better anticipate this symptom, schedule monitoring and treatments, and educate patients and caregivers.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages 131-139.e2"},"PeriodicalIF":3.2,"publicationDate":"2025-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143967440","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Advance Care Planning Challenges in Adult Congenital Heart Disease","authors":"Rhea J. Patil MD, MPH ,&nbsp;Gina Kang MD, MPH, MHS ,&nbsp;Sharon Whyte RN ,&nbsp;Kathyrn Schlenker DO ,&nbsp;Karen K Stout MD ,&nbsp;Jill M. Steiner MD, MS","doi":"10.1016/j.jpainsymman.2025.04.004","DOIUrl":"10.1016/j.jpainsymman.2025.04.004","url":null,"abstract":"<div><div>Due to advances in congenital heart disease management, there are now more adults than children living with congenital heart disease in the United States. This population of over 1.4 million people is expected to continue to grow rapidly as a result of improving survival. However, patients with adult congenital heart disease continue to face increased rates of morbidity, hospitalizations, and medical interventions compared to the general population, in addition to elevated mortality. Therefore, comprehensive advance care planning is integral to caring for this patient population. Yet despite recommendations for early advance care planning in adult congenital heart disease, evidence suggests that it is rarely performed prior to patients’ end-of-life. As demonstrated in this case, there are several challenges to advance care planning in this population which may account for this finding. Difficulty with accurate prognostication combined with the relatively young age of these patients has been reported to contribute to clinician hesitancy in initiating advance care planning prior to the onset of serious illness. Patients may have difficulty grasping their shortened life expectancy and may not feel ready to discuss serious illness care ahead of its onset. Furthermore, comorbid poor mental health and other psychosocial challenges are frequently prevalent in this population, further complicating matters. Therefore, patients with adult congenital heart disease may need more directed support with the advance care planning process, and early involvement with specialist Palliative Care can be invaluable. Further research specific to this population is needed to create a framework for successful palliative care delivery.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 2","pages":"Pages e176-e180"},"PeriodicalIF":3.2,"publicationDate":"2025-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143970615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assuring the Provision of Palliative Care as an Ethical Duty for All Physicians","authors":"Amber R. Comer PhD, JD ,&nbsp;Daniel Sulmasy MD, PhD","doi":"10.1016/j.jpainsymman.2025.03.023","DOIUrl":"10.1016/j.jpainsymman.2025.03.023","url":null,"abstract":"<div><div>Although palliative care is an evidence-based, essential component of care for patients with serious or critical illness and at the end-of-life, access to palliative care continues to be limited by inaccurate definitions, misrepresentation, stigma, and neglect. To help physicians and patients to overcome barriers limiting the provision of palliative care, the American Medical Association (AMA) has recently adopted policy and a new opinion in the Code of Medical Ethics which establishes an ethical duty for all physicians, in all specialties, to assure the provision of palliative care to patients who stand to benefit. Additionally, the new policy and <em>Code</em> opinion expand the depth and breadth of what palliative care access and delivery entail and address misconceptions that have resulted in barriers to the delivery of palliative care.</div><div>Importantly, the AMA’s recognition of the provision of palliative care as an ethical imperative obliges all physicians, regardless of specialty, to assess and address the palliative care needs of patients and to do so earlier in the disease course. Additionally, the policy and Code opinion, and lay the foundation for improving access and education about palliative care through law and policy reform<span><span>.⁸</span></span> This article discusses the importance and significance of the new American Medical Association policy and Code of Medical Ethics opinion on palliative care which provides long overdue and necessary support and guidance for all physicians to provide this ethically imperative medical intervention that improves patients’ and their caregivers’ quality of life.</div></div>","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"70 1","pages":"Pages e25-e27"},"PeriodicalIF":3.2,"publicationDate":"2025-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144014956","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Ethics of Artificial Intelligence-based Screening for End-of-life and Palliative Care","authors":"Kathryn Huber MD,&nbsp;Matthew DeCamp MD PhD,&nbsp;Ahmed Alasmar,&nbsp;Mika Hamer PhD MPH","doi":"10.1016/j.jpainsymman.2025.02.031","DOIUrl":"10.1016/j.jpainsymman.2025.02.031","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Outcomes&lt;/h3&gt;&lt;div&gt;1. Participants will be able to comprehend the use of artificial intelligence-based prognostication as a form of “screening” for end-of-life.&lt;/div&gt;&lt;div&gt;2. Participants will be able to analyze the ethical challenges that could shape the implementation of artificial intelligence-based prognostication in palliative care and apply ethical principles that can help guide that implementation.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Key Message&lt;/h3&gt;&lt;div&gt;Based on qualitative interviews at four U.S. medical centers, palliative care team members view artificial intelligence-based prognostication tools as a form of “screening” – so understood, the established ethics principles governing screening can yield concrete recommendations for the ethical use of these AI prognostic tools.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Abstract&lt;/h3&gt;&lt;div&gt;Artificial Intelligence (AI) tools for healthcare applications are rapidly emerging, with some tools already being used and more on their way. One example is AI-based prognostication tools which can predict patient mortality automatically and with accuracy that outperforms clinicians and other available tools. In palliative care, prognostication may be particularly important; these tools may change practice in ways we do not fully understand and raise important ethical and implementation questions.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Objective&lt;/h3&gt;&lt;div&gt;To identify the ethical challenges that could shape implementation of AI-based prognostication in palliative care.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;We conducted semi-structured interviews with 45 palliative care physicians, nurses, and other team members from four academic medical centers. Interviews were transcribed and analyzed using grounded theory.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Results&lt;/h3&gt;&lt;div&gt;A central theme emerged: implementation of AI-based prognostication was seen as a form of “screening” for end-of-life (EoL). While the idea of prognostication as screening for EoL is novel, the ethics of screening in other clinical contexts is well-established. For this reason, we drew on a model of screening ethics (1) as a framework for our analysis. Interpreting our interview data through this lens, we identified four principles to guide the implementation of AI-based prognostication as screening: (i) screening for EoL should be evidence based, (ii) screening for EoL should take opportunity cost into account, (iii) screening for EoL should distribute costs and benefits fairly, and (iv) screening for EoL should offer respect for persons and their dignity.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Conclusion&lt;/h3&gt;&lt;div&gt;Our findings help us understand how palliative care team members view emerging AI-based prognostic tools and offer guiding principles for their implementation as screening for EoL. In the future, it will be important to define the role of screening in this context and to understand how the result of the screening affects decision-making for patients, families, and care teams.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;References&lt;/h3&gt;&lt;div&gt;1.Bailey M","PeriodicalId":16634,"journal":{"name":"Journal of pain and symptom management","volume":"69 5","pages":"Pages e425-e426"},"PeriodicalIF":3.2,"publicationDate":"2025-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143807047","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}