Journal of palliative medicine
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Background: Adults with advanced cancer experience profound future uncertainty, reflected in elevated fear of cancer progression (FoP) and cancer-related trauma symptoms. These symptoms are associated with physical symptom burden and poorer quality of life, and few interventions exist to manage them. Objective: To develop and pilot a written exposure-based coping intervention (EASE) focused on worst-case scenarios among adults with advanced cancer reporting elevated cancer-related trauma symptoms or FoP. ⋯ Primary outcomes of cancer-related trauma symptoms and FoP improved significantly from pre to both follow-ups by predominantly large effect sizes. Secondary outcomes of anxiety, depression, hopelessness, fear of death/dying, and fatigue, and most process measures improved significantly by FU1 or FU2. Conclusions: EASE, a novel adaptation of written exposure therapy, is a promising approach to reducing FoP and cancer-related trauma symptoms among adults with advanced cancer that warrants further study.
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Case Reports
Successful Management of Terminal Delirium With Transdermal Blonanserin Patch in a Terminally Ill Cancer Patient.
Delirium is a distressing condition in terminally ill cancer patients, often treated with antipsychotics. Administering them orally, subcutaneously, or intravenously can be challenging in severely agitated patients. Transdermal antipsychotic patches offer an alternative, but their use for terminal delirium remains underexplored. ⋯ The patch was easily applied daily without notable adverse events. However, he deteriorated a week later with an estimated survival of days, ultimately requiring continuous midazolam for refractory agitation. This case underscores the potential of transdermal blonanserin patches for delirium in terminally ill cancer patients, emphasizing the need for future prospective studies.
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Importance: Concordance between physician orders for life-sustaining treatment (POLST) preferences and treatment at end-of-life is an important outcome measure of providing patient-centered care. Objectives: We determine whether the COVID pandemic affected clinician ability to provide goal concordant care and replicate our previous report on care concordance and change in patient preferences over time with a larger sample size. We also investigate the quality of POLST completion to determine the number of documents completed with an advance care planning (ACP) conversation or a decision maker present. ⋯ We found that 82% of POLSTs were created in the context of an ACP conversation, 77% with a decision maker present. Conclusion: High levels of goal concordant care were maintained during the pandemic. Because patient wishes evolve over time, clinicians should be trained and supported to revisit care preferences across the illness trajectory.
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Background: Older adults with serious illness near the end-of-life often receive invasive treatments. We developed a conceptual model called clinical momentum that describes system-level forces producing a trajectory of care that is difficult to modify and contributes to overtreatment. We sought to evaluate the empirical fit of our model by examining an event with clear guidelines against intervention: permanent feeding tube placement in patients with advanced dementia. ⋯ Eventually, clinicians had to address the temporary tube, which was framed to families as a decision to place a permanent feeding tube or withdraw treatment. Conclusion: Elements of the model-including recognition-primed decision-making, "fix-it," and sunk costs-contributed to placement of a feeding tube, which set in motion a path toward intervention long before a goals-of-care conversation occurs. Clinical momentum expands our understanding of overtreatment at the end-of-life and may reveal opportunities to reduce other nonbeneficial interventions.
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Background: Faculty development (FD) is critical to the implementation of competency-based medical education (CBME) and yet evidence to guide the design of FD activities is limited. Our aim with this study was to describe and evaluate an FD activity as part of CBME implementation. Methods: Palliative medicine faculty were introduced to entrustable professional activities (EPAs) and gained experience estimating a learner's level of readiness for entrustment by directly observing a simulated encounter. ⋯ Results: Participants were able to use the EPA framework when estimating the learner's readiness level for entrustment. Significant improvements in attitudes and level of confidence for several knowledge, skill, and behavior domains were maintained over time. Conclusions: Simulated direct observation and facilitated debriefs contributed to preparing both faculty and learners for CBME and EPA implementation.