(Death Rattle)

Pain persisting or increasing

Opioid for mild to moderate pain

± Non-opioid

± Adjuvant

2

Source:J Am Oeriatr Soc 2002:00:52Ob-5224 aridOn ContinuingPractice 1093:20 20-25 olid Ain Fam Physician 2009;79|12) 10S9-I0OS

Pain persisting or increasing

Pain Management

• tee Anesthesia. A25 Non- opioidiAdjuvant

Pain Syndromes

• see Neurology, N43 Figure 3. WHO’s Pain Relief ladder

WHO’s Pain Relief ladder,available

from:https://www.who.int/cancer/

palliative/painladder/en/”

Care of the Dying Patient

General Predictors of Decline in the Final Months of Life

• decreasing activity -functional performance status declining,limited self-care, in bed or chair 50% of

day, and increasing dependence in most i\DLs

• co-morbidity - biggest predictive indicator of mortality and morbidity

• general physical decline and increasing need for support

• advanced disease - unstable, deteriorating complex symptom burden

• decreasing response to treatments, decreasing reversibility

• choice of no further active treatment

• progressive weight loss (>l

()%) in the past six months

• repeated unplanned/crisis admissions

• sentinel event (e.g. serious fall, bereavement, transfer to nursing home)

• serum albumin <25 g/L

• considered eligible for terminal illness disability benefits

See landmark Palliative Care Inals fable for more

dormation on the study hy Haylor etal..1999.which

d etails the effectiveness of advanced practice wisecentered discharge planningand home follow-up

intervention for older aged individualsat risk foi

hospitalreadmissions.

See landman Palliative Care Inals fable for moie +

information on study by Christakis et at.2000.whxh

d eta sdoctors' prognostic accuracy in terrmrally

dpatientsaril to evaluate the determinants of that

accuracy.

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Changes in the Last Hours of Life

• decreased level of consciousness

• changes in breathing pattern (Cheyne-Stokes breathing)

• airway secretions causing noisy breathing

• inability to swallow safely and increased risk of aspiration

• delirium (terminal restlessness)

• mottling of the hands, feet, and legs

• cool extremities

5 Dimensions of a Good Death

OuaMy Entf-01-UleCan:Patents'

fenpaclms JAMA

1999;281:MJ-168

• Pain/symptom management

• Avoiding prolongation of dying

• Achieving a sense of control

. Relieving burden on others

• Strengthening relationships with

loved ones Care of the Patient in the Final Days of Life

• educate the family on the physiological changes in the dying process and discuss potentially difficult

decisions(e.g.hydration)

• have a plan in place for an expected death in the home (EDITH), who to call (not 911), and how the

death certificate will be made available to the funeral home

• if the patient is unable to swallow, administer essential medications by non-oral routes (e.g. SC,

gastrostomy tube, IV, nasal,oral and rectal transmucosal, transderma!), with SC being the preferred

option

• discontinue non-essential and potentially inappropriate medications (e.g.for primary and secondary

prevention);review other measuressuch as 1V/SC hydration and consider stopping if no longer

beneficial

Psychosocial and Spiritual Needs

• palliative care assessment includes addressing psychosocial and spiritual well-being

• psychosocial needs pertain to the psychological and emotional well-being of patients and their carers,

including concernssuch asself-esteem, adaptation to illness, communication, and social functioning

• patient'

s psychosocial experience isfurthershaped by the experience of pain and othersymptoms

related to the condition and itstreatment

• spiritual needs pertain to the manner in which the patient expresses meaning, value, and purpose in

life. May include, but is not limited to, religious practices or philosophical reflection

Approach to Assessing Psychosocial and Spiritual Needs

• holistic psychosocial assessment can help identify supports a person might need during their illness.

Psychosocial issues can manifest as physical symptoms(e.g. pain, constipation, nausea). Iherefore, it

is important to be aware of physiological symptoms that may indicate depression and anxiety

• mental and emotional needs-fear,worry,insomnia, panic,anxiety, nervousness, or lack of energy

• social needs-family dynamics, communication,social and cultural networks, perceived social

support,finances, intimacy, living arrangements, caregiver availability, etc.

• cultural needs- beliefs and preferences, linguistic needs, health behaviours, traditions, rituals, and

cultural barriers to accessing health

• to further explore questions about spirituality, the FICA spiritual assessment tool may be used

• FICA - the four components to cover during a spiritual care assessment are: l aith or beliefs,

Importance of those beliefs, patient’s participation in a religious orspiritual Community, and how

healthcare providersshould Address the patient'

s health care issues

Interprofessional Care Plan for Psychosocial and Spiritual Needs

• interprofessional team of care providers including physicians, nurse practitioners, nurses,social

workers, psychologists, chaplains,spiritual advisors, pharmacists, and physical and occupational

therapists assist in the following interventions:

home care, respite care,social networks and activities, problem-solving and education, one-onone therapy, and group work

End-of-Life Decision Making

Types of Discussions

Advance Care Planning Discussion

• it involves a mentally capable patient:

1. identifying their SUM by preparing a Power of Attorney (POA).If no POA is chosen, then the

SDM hierarchy list in the Health Care Consent Act applies

2. discussing one’s values, beliefs,and wishes for future health care,should one become incapable of

making health care decisions

Goals of Care Discussion

• exploratory discussion where the health care provider and patient discuss the patient'

s current

medical issues, their understanding of their illness, and possible treatments and outcomes. May or

may not include discussion about code status

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Code Status Discussion

• discussion with patient about level of intervention they would want in the event of cardiac or

respiratory arrest

• full code - patient would like to receive CPU, delibrillation, and life supp

Do Not Resuscitate (DNR) - patient would not like to receive CPR or life support, only active

medical management

comfort measures- patient would not like to receive CPR,life support,or active medical

management

• Allow Natural Death (AND) - alternative term to DNR. Often a gentler term to help with the

discussion

• CPR is rarely effective in the patient with advanced incurable illness

DNR order is almost always consistent with palliative goals of care

ort

When to Initiate EOL Care Discussions

• recent hospitalization for serious illness, or during a transition in care

• severe progressive medical condition(s)

• death expected within 6- 12 mo

• patient rewritten will and/or spiritual wishes

• if the patient requests medical assistance in dying (MAID)

Power of Attorney for Personal Care

• see Ethical, Legal, and Organizational Medicine, KLOM14

Communication

• strong communication is critical in all areas of medicine.This is especially true in palliative

care, where difficult decisions must be made regarding goals of care, EOL care, and disclosure of

information

• be cognizant of how a patient'

s (and their family'

s) beliefs, values, and wishes may impact their

decision making and/or their emotional response during palliative care conversations

• use both verbal and non-verbal means of communicating empathy and caring to build rapport, and

help de-escalate the intense emotions that patients may experience including anger,grief, and feeling

overwhelmed

Approach to Communicating Bad News

SPIKES

S -Setting up the interview: create privacy by bringing the patient to a quiet and comfortable

environment. Ensure you have enough time to have an extended conversation with the patient.Ask

them if they wish for family members or othersupports to be present

P - assess Perception: what does the patient and/or their family understand about their illness at

present? Use open-ended questions and fill any major gaps to ensure mutual understanding

1 -Invitation: how does the patient wish to hear the information? How many details do they want? Do

they want to first understand the process that led the care team to their diagnosis/prognosis/treatment

decision,or do they just want to hear the news upfront?

K - Knowledge sharing: provide the information based on the preferences expressed in the “invitation"

section in small segments using non-technical terms

E - Emotions: respond to the patient'

s/family'

s emotions. Allow them time to process the information.

Silence is okay. Offer to answer any questions they may have,but also recognize that some patients may

wish to discuss further details at a later time

S -Strategy and Summary:if the patient and their family are comfortable,summarize the

conversation and discuss nextsteps

Estimating Life Expectancy

• when asked about prognosis, be wary of being overly specific

• use time framessuch as hours to days,days to weeks, weeks to many weeks, or months

• clinicians consistently overestimate survival when prognosticating

Collaboration

Interprofessional Team

• interprofessional team may include the following members:

physicians:may be primary care providers, or have specialty training in palliative care; they

provide medical management and symptom relief

nurses: provide patient education in addition to clinical nursing;often with advanced practices in

setting of hospice or home care

social workers/case managers:facilitate advance care planning conversations and other

psychosocial interventions for patients and their families

pharmacists:timely provision of medications, assessment of medication plans

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occupational therapists:identify important life roles and activitiesto patients,and address

barriersto performing these activities

physiotherapists:optimize patient comfort by maintaining physical function during disease

progression

• dieticians:optimize a nutritional plan focused on the patient'

s needs and wishes

spiritual care workers:provide spiritual and religious care for persons with life-limiting disease

• all members of the palliative care team provide assessment of palliative care needs through the use of

validated tools such as the ESAS and the PPS

• palliative care team collaborates through ongoing care conversations with the patient and their family

to discussthe patient'

s condition, course of illness, treatment options, goals, and plan of care

Suffering

Definition

• a multidimensional experience of severe distress that diminishes an individual’s ability to find

peace in their present situation, with contributions from physical symptoms, psychological distress,

existential concerns, and social

-relational worries

Key Points

• suffering can occur at any moment within the palliative context

• suffering issubjective and unique to the patient

• anguish and despair arc justifiable responses to difficult human situations

• patients may suffer not only from illness, but also from treatments

• suffering is not confined to physical symptoms

• it is impossible to anticipate the source of someone’ssuffering

Sources of Suffering

• physical concerns

impaired activities

• loss of physical independence

symptoms (e.g. pain, tiredness, poor sleep, loss of appetite)

• social-relational concerns

• family distress or dysfunction

burden on others

• psychological concerns

fear or dread of the unknown

loss of balance and control

difficulty accepting the situation

overwhelmed by life circumstances

comorbid depression and anxiety

• spiritual concerns

unfulfilled needs of love, virtue, faith, and/or hope

• questioning meaning of life or death

anger towards a higher being (as defined by the individual)

viewing illness as punishment

• existential concerns

loss of dignity

• desire for death

loss of will to live

Options to Relieve Refractory Suffering

• palliative sedation therapy:the use of pharmacological agents to reduce consciousness. Only

considered in patients who have been diagnosed with advanced progressive illnesses and reserved for

treatment of intolerable and refractory symptoms

• medical assistance in dying (MAID):in Canada,a specific process that occurs when a mentally

competent patient makes a written request to end one’slife. The patient is interviewed by 2 different

clinicians, one of which is the MAID provider.A physician or nurse practitioner administers

medicationsthat cause a person’s death or the patient is prescribed medications to self-administer

that will cause one’

s own death

there are currently 2 pathways to MAID in Canada; pathway 1 where death is foreseeable and

pathway 2 where the patient has a serious and incurable illness, disease,or disability but death is

not immediately foreseeable

recent changes have also included a waiver of final consent in situations where the individual may

lose decision-making capacity before their preferred date of receiving MAID if their natural death

is reasonably foreseeable

• legislation in Canada continuesto be under parliamentary review as new patient groups and

circumstances are added

» note:currently, patients with mental illness as their main diagnosis are excluded from receiving

MAID. However, this will be revisited in the spring of 2023

https://wvm.justice.gcxaleng/cj

-jp/a(l’

am/bk-di.htinl

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Types of Grief

• anticipatory grief -feelings of grief occurring before an impending loss, including being concerned

for the dying person, balancing conflicting demands, and preparing for death

• acute grief -immediate reaction to the death of a loved one. In the majority of cases,support from

family and friends over time will help the bereaved accept the loss

• complicated grief- unanticipated progression of grief,which severely interferes with a person’s ability

to function.Characterized by prolonged duration, maladaptive thoughts, dysregulated emotions, and

dysfunctional behaviours; depression and anxiety may be prevalent

Self-Care

Definition

• proactive, holistic pursuit of personal well-being in tandem with professional responsibility for patient

well-being

Benefits

• balances compassion for oneself and compassion for others

• translates improvements in professionals' quality of life to improvements in patients’ care

positively predicts competence in coping with death and achieving compassion satisfaction

negatively predicts risk of fatigue and burnout

• requires and cultivatesself-awareness, i.e.the culmination of knowledge of and empathy for oneself

• promotessustainable resilience through the development of coping skills, the balance between

professional demands and personal needs, and the commitment to overall well-being

Strategies

• within the workplace:individual regulation of workload demands and establishment of boundaries,

opportunity for team bonding/debriefing, promotion of resources/supports that can attend to

professionals'

needs, and development of a culture supportive of and conducive to self-care

• beyond the workplace: a range of health-promoting behaviours (e.g. balanced diet,sleep hygiene,

exercise, meditation,interpersonal fulfillment,spiritual practice)

Paediatric Palliative Care

Unique Considerations for Paediatric Patients

• the unit of care in paediatric palliative care is always the family and the afflicted child.This includes

siblings,who are often affected in various ways

• ideally should be offered early after diagnosing a potential life-limiting or life-threatening disease and

continued through the course of treatment,along with standard/curative care

• respite servicesfor families is a key aspect of palliative care for medically complex and technologydependent children

• bereavement support to parents and siblings after the death of a child is a standard offering

emotional maturity and cognitive abilities vary between children and adults, and are determined

by the developmental level of the child rather than their chronological age

• unique paediatric life-threatening illnesses-less than 30% of patients referred to paediatric

palliative care teams have cancer;the majority have congenital or acquired neurologic

impairment, many of whom are technology-dependent

unique challenge of dealing with the child, parents, and siblings

decision-making authority, even in matters related to HOL, depends on the young person'

s

capacity. However, many decisions are family-centered, and made with the paediatric patient and

the parents together

Predominant Pediatric Conditions

Receiving Palliative Care:

1. Gcnetic/congenital disease (40.8%)

2. Neuromuscular disease (39.2%)

3.Cancer (19.8%)

4. Respiratory disease (12.8%)

5.Gastrointestinal disease (10.7%)

Table 3. Categories of Paediatric Patients Who May Benefit From Palliative Care

Category1 Life-threateningconditionsfor whichcurative treatmentmay be feasible but canfail

Palliative care is involved when treatment fails or during acute crisis

Palliative care isnolonger requiredupon achieving long-term remission or successful treatment

e.g.cancer,irreversible organ failure

Conditions in whichpremature deathis inevitable

Intensive treatment over a long period of time to prolong life and allow normal activities

e.g.cystic fibrosis.Ouchenne muscular dystrophy

Progressive conditions without curative treatment options

Irealmenl is eiclusrvely palliative and can extend over many years

e.g. Batten disease

Irreversible but non-progressive conditions causing severe disability

e.g.severe cerebral palsy,multiple disabilities alter brain or spinal cord injury

Category 2

Category 3

Category 4

Source:Aguide tochildren's palliative care:supporting babies, children and young people with lite-lliniting and life-threatening condiUons and

their families.Together lor Short lives2018 +

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Assessment Tools

Symptom Screening in Paediatrics Tool (SSPedi)

• used in children age 8-18 yr to assesssymptoms over time and the efficacy of interventions

• symptoms rated on a five-point descriptive Likert scale

• assesses depression, anxiety, irritability, memory/cognition, changes in appearance, fatigue, mouth

sores, headache, pain, tingling/numbness of extremities, N/V, appetite, changes in taste, constipation,

and diarrhea

Mini-SSPedi

• a revised SSPedi geared towards children -1-7 y/o

• assesses the same 15 symptoms

• uses a three-point, face-based Likert scale

• keep in mind the child'

s stage of development when interpreting these tools

• children 4-5 y/o can describe concrete aspects of their own health

introspection develops around ages 6-8 y/o

Memorial Symptom Assessment Scale (MSAS)

• used in children 7+ y/o

• measures frequency,severity, and distress associated with 32 common physical and psychological

symptoms

• uses a five-point Likert scale

• used in both clinical and research settings

Symptom Management

• children are often aware of their condition, and open communication with the child in regard to

diagnosis and prognosis is encouraged to reduce anxiety and fear

child’s stage of development and cognitive abilitiesshould be considered when discussing

concepts of illness, treatment decisions, LOL, and dying

• symptoms encountered near LOL, and their respective management are similar to that in adult care

(see Table 2, PM4).However, the following are unique in paediatric management:

• shared decision making involving the child (to the extent possible or desired), the parents, and

the healthcare providers typically guides treatment and LOL care

• symptom management may be over the course of years and therefore may require a transition

plan into adult palliative services

• play therapy and unstructured play reduces anxiety, depression, and aggression

• creating a sense of normality in the child'

s life aids in emotional wellbeing (e.g. seeing friends,

attending school, parental discipline)

• the patient'

s pain and anxiety often correlate with parental anxiety and quality of life, and

therefore managing these symptoms benefits the family unit

• siblings should also be offered psychological supports

Landmark Palliative Medicine Trials

Trial Name Reference Clinical Trial Details

PALLIATIVE APPROACH TO CARE

Temeletal.,2010 HEJM 2010:363:733 742 Title:Early Palliative Care lor Patients with Metastatic Non-Small-Cell Lung Cancer

Purpose:To examine the effect of introducing early palliative care after diagnosis of metastatic non-small-cell lung cancer on patientreported outcomesand end- of-life care.

Methods:Patients (n-322) were randomized to receive either an early nurse-led palliative care intervention addressing physical and

psychosocial needs in addition to usual oncologic care vs.routine oncology care.Primary outcomes includedOoL.symptom intensity,and

mood.

Results:Of 151 randomized patients. 27 passed away, and 107 (86% of the remaining patients) completed assessments.Patients assigned

to early palliative care had a better OoL,lower depressive symptoms,and longer median survival vs.standard care (11.6 mo vs.8.9 mo.

P-0.02).

Conclusions:Early palliative care led to significant improvements inboth OoL and mood among patients.Despite lesser aggressive EOL

care,theintervention group had longer survival.

Title:Randomized Controlled Trial of Early Palliative Care for Patients With Advanced Cancer

Purpose:To assess the impacts of early palliative care on patients withadvanced cancer.

Methods:RCI consisting of 461patients who had advanced cancer,and a prognosis of 6-24mo.Patients were randomized to receive

consultation and follow-up by a palliative care team or to receive standard cancer care.The outcomes of interest were quality of life,

assessed using Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACTT-Sp) at 3 mo.and Oualily of Life at the End

of Life (OUAL-E) scale: symptom severity,assessed using Edmonton Symptom AssessmentSystem (ESAS):and satisfaction with care,

assessed using FAMCAREP16.

Results: Results show that there was no significant difference in the FACIT-Sp score at the primary endpoint and there was animprovement

in quality of life by «2.25 points on the OUAlE-scale within the treatment group compared to the control.There was also a significant

difference in satisfaction with the quality ol care by «3.79 points on the FAMCARE-P16 scale within the treatment group compared to the

control.There was no significant difference in symptom severity.

Conclusions: Although there was no change in quality of life at theprimary endpoint,improvements in the OUAL E and fAMC ARE P16

scores are promising and warrant further research.

HCT01248624 Lancet.2014 May

17;383(9930):1721-30.

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Trial Name Reference Clinical Trial Details

COSMIC Lancet. 2022:399|10325):656 Title:Effectiveness of a three-step support strategy for relatives of patients dying in the intensive care unit

Purpose:Evaluate the effectiveness of a proactive communication and support intervention involving physiciansand nurses at reducing

prolonged grief in relatives.

Methods: RCT consisting of 87S relatives aged >18 yr who have made a decision lo withdraw or withhold life support.Patients were

randomiicd to receivestandard olcaie support and communication, or a physician- driven,nurse-aided,three-step support strategy. The

outcome of interest was theproportion of relatives with prolonged grief as indicated by a score >30 on the Prolonged Oriel Scale (PG-13).

6 mo after the death.

Results:A smaller proportion of relatives randomiced to receive the involved communication strategy experienced prolonged grief (15%)

when compared to the control group (21%).Associated PO-13 scores were also comparatively lower in the group that received the involved

communication strategy.

Conclusions:A physician-driven,nurse-aided,three-step support strategy is effective atreducing prolonged grief in relatives coping with

the loss of a family member.

Title: Effects of a Palliative Care Intervention on Clinical Outcomes in Patients with Advanced Cancer:the Project ENABLE IIRandomiied

Controlled Trial

Purpose: To determine the effect of a nursing-led intervention on Ool. symptom intensity,mood,and use of resources inpatients with

advanced cancer.

Methods:Patients wererandomiced lo receivemulti-component intervention vs.usual care (n'322).Intervention included telephonebased care by advanced palliative care trained nurses,who provide structured educational and problem-solving sessions,to encourage

patient activation,sell-management,empowerment andfollow-up at least monthly with every patient.Primary outcomesincluded OoL.

symptom intensity,and mood.Intensity of service was measured using days in the hospital and number of ED visits.

Results:Longitudinal intention-to-treat analyses for the total sample revealed higher QoL.lower depressed mood,and a trend toward

lower symptom intensity.Similar results were seen among patients who passed away,except there was no change in symptom intensity.

No differences were noted in the number of days in the hospital.ICU.or ED visits.

Conclusions: A nurse- led,palliative care-focused intervention addressing physical and psychosocial care along with oncology care

improved scores for Ooland mood.

Title:Early vs.Delayed Initiation ol Concurrent PalliativcOncology Care

Purpose: To determine the impact of early vs.delayed initiation of concurrent palliative oncology care on mood, symptom impact,quality

of life,and 1-yrsurvivalrale.

Methods:RCT consisting of 207 patients with advanced cancer.Patients were randomized to receive in-person palliative care (PC)

consultation,structured PC telehealth nurse coaching sessions,and monthly follow-ups upon admission or within 3 mo of admission.The

outcomesof interest were quality of life,symptom impact,mood.1-yr survival,hospital/intensive care unit days,emergency room visits,

chemotherapy in the last14d,and death location.

Results:Mood andquality of life were not significantly different between the two groups.1-yr survivalrates were greater in the early

intervention compared to the delayed intervention.Relative rates of hospital days,ICU days,emergency room visits,and chemotherapy in

the last 14 d of life were similar between the two groups.

Conclusions:Although, self-reported outcomes,andresource use were not significantly different between the Iwo groups,there wasan

improvement in1- yr survival rales.

Title: Efficacy of Communication SkillsTraining for Giving Bad News and Discussing Transitions to Palliative Care

Purpose: To evaluate the efficacy ol a residential communication skills workshop (Oncotalk) for medical oncology fellows in changing

observable communication behaviours.

Methods:A cohort of 115 medical oncology fellows took part inOncotalk which emphasized skills practice in small groups.The primary

outcomes includedparticipant communication skillsmeasured during standardized patientencounters before and after the workshop in

giving bad news and discussing transitions to palliative care.Comparisons were made using each participant as his or her own control.

Results:Post-workshop encounters showed that participants improved in bad news skills (P*0.001) and transition skills (P'

0.001).

Conclusions:Oncotalk was a successful teaching model for improving communication skillsfor postgraduatemedical trainees.

ENABLE II JAMA 2009:302:741-749

J Clin Oncol. 2015 May

1;33(13):1438 - 45

ENABLE III

Back el al..2007 JAMA Intern.Med. 2007:

167:453-460

Associations between end- JAMA. 2008:300(14):1665- 73 Title:Impacts of End of life (EOL) discussions

of-life discussions,patient

mental health,medical

care near death,and

caregiver bereavement

adjustment

Purpose: lodetcrminc whether end of life discussions with a physician will result inless intensive intcrvenlions.

Methods:longitudinal cohort study consisting of 332 pairs consisting of a patient withadvanced cancer and then caregiver. Pans were

followed from admission to death. Outcomes of interest were medicalinterventions including ventilation,resuscitation.and hospice in the

final week oflife.

Results:Of the 332pairs.123 patients received an EOldiscussion.This did not result in higher rates of major depressive disorder.

However.EOL discussions were associated with earlier admissions to hospice (65.6% vs.44.5%).lower rates of ventilation (1.6% vs.11%),

resuscitation (0.8% vs.6.7%).andICU admission (4.1% vs.12.4%).

Conclusions: EOL discussions result in less aggressive medical care and earlier hospice admission.

PATIENT ASSESSMENT

Naylor elal..1999 JAMA 1999:281:613-620 Title:Comprehensive Discharge Planning and HomeFollow-up of Hospitalized Elders: A Randomized Clinical Trial

Purpose: To examine effectiveness of advanced practice nurse -centered discharge planning and home follow-up intervention for ciders at

risk for hospital readmissions.

Methods:Patients aged >64 yr were randomized toreceive comprehensive discharge planning and home follow-up vs.routine discharge.

Primary outcome was time to first readmission.

Results:Intervention group had longer time to first readmission,fewer multiple readmissions,fewer hospital days per patient,and lower

healthcare costs.Control group patients were more likely than intervention group patients tobe readmitted at least once.Ho significant

differences were notedin postdischarge acute care visits,functional status,depression,or patient satisfaction.

Conclusions:Intervention demonstrated great potentialinpromoting positive outcomes for hospitalized elders at high risk for

rehospitalizalion whilereducing costs.

Title: Extent and Determinants olError In Doctors'Prognoses in Terminally IIIPatients:Prospective Cohort Study

Purpose: Todescribe doctors' prognostic accuracy in terminally ill patients and loevaluate the determinants ol that accuracy.

Methods: Prospective cohort study involving 343 doctors who provided survival estimates for 468 terminally illpatients at the time of

hospice referral.Main outcome measures were the estimated and actual survival of patients.