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ContextPalliative care offers patient and family centered approaches that may mitigate risk of caregiver burden and poor mood.ObjectivesTo determine whether a palliative care intervention (CONNECT) improved burden, mood, and self-efficacy among caregivers of patients with advanced cancer.MethodsIn this cluster randomized trial, patients and their caregivers were recruited from 17 Oncology clinics in Pennsylvania. Participants attended nurse-led monthly visits, addressing patient symptoms, goals of care, and advance care planning. At baseline and three months, we measured caregiver burden using Zarit Burden Interview (ZBI-12; range 0-48), caregiver anxiety and depression using Hospital Anxiety and Depression Scales (HADS-A, range 0-21; HADS-D, range 0-21). We measured caregiver self-efficacy at three months using Caregiver Inventory (CGI; range 0-189).ResultsWe enrolled 441 caregivers and 381 completed three-month assessments. We found no significant differences in caregiver burden (adjusted mean difference -0.39; 95% CI -1.07-0.29, P=0.90), depression (adjusted mean difference -0.22, 95% CI -0.97-0.55, P=0.26), or anxiety (adjusted mean difference 0.09; 95% CI -1.25-1.43, P=0.58), between the intervention and standard care at three months. Caregiver self-efficacy was higher at three months in the intervention compared to standard care (adjusted mean difference 9.36; 95% CI 0.95-17.77, P=0.030).ConclusionCaregivers in CONNECT did not experience improved burden or mood, however, they reported higher self-efficacy compared to caregivers receiving standard care. This study highlights the need for strategies to optimize caregiver outcomes in palliative care interventions.

Context Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits. Objectives Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities. Methods Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery. Results A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support. Conclusion Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.

CONTEXT: Little attention has been given to social environmental factors associated with advance care planning (ACP) among African Americans or persons living with advanced Human Immunodeficiency Virus (PLHIVs). OBJECTIVES: The present study aimed to identify support network factors that affect the likelihood of naming a decision-maker and of talking to family/friends and doctors about ACP among vulnerable PLHIVs. METHODS: PLHIV were recruited from a large urban HIV clinic. A social support network inventory was used to calculate numbers of persons available for various types of support. Characteristics of network members were also collected. Multivariable logistic regression models were fit to examine associations between social network factors and ACP discussion, adjusting for age, sex, education and total number of network members. RESULTS: The sample (N=370) was mostly African American (95%), male (56%) and 48% had less than a high school education. Almost half the sample (48%) had talked to their family/friends or doctor about ACP and 34% had named a medical decision-maker. Adjusted analysis revealed that talking about ACP with family/friends was associated with female sex and a larger, closer support network who provided health information and physical assistance. Talking to doctors about ACP was associated with larger support networks who provided physical assistance but lower numbers from whom emotional support was received. Naming a decision-maker was associated with greater numbers of network members who provided emotional support, health information, and medication adherence reminders. CONCLUSION: The findings revealed aspects of family/ support network structures and caregiving function associated with ACP in a population with often vital yet vulnerable networks.

In the era of effective antiretroviral therapy, persons living with HIV/AIDS (PLWHA) are living longer, transforming HIV from a universally fatal disease to a serious chronic illness, warranting discussions between patients and their loved ones about advance care planning (ACP). Evidence is needed on factors associated with patients' likelihood to discuss ACP with loved ones.To further characterize factors associated with successful ACP in PLWHAs with their loved ones, we examined associations between patients having ACP discussions with the need for assistance with personal care, chronic pain, life satisfaction, prior family disagreements over health care decisions, sex, age, and interference in daily routines due to memory problems.Data were from the Affirm Care study (N = 370), which examined social and environmental factors associated with health outcomes among PLWHAs and their informal caregivers.Slightly more than half of respondents discussed ACP with loved ones (57%). In adjusted analysis, higher levels of chronic pain (odds ratio [OR] = 2.09, P = 0.045), needing assistance with personal care (OR = 1.63, P = 0.023), greater life satisfaction (OR = 1.02, P = 0.002), prior family arguments over health care decisions (OR = 2.80, P 0.001), and female sex (OR = 2.22, P = 0.001) were associated with higher odds of discussing ACP with loved ones, whereas age, drug use, education level, depression, and memory problems were nonsignificant.These results suggest that interventions to increase ACP among PLWHAs and their loved ones should target males. The findings also suggest PLWHAs with chronic pain, the need for assistance with personal care, and those with a history of prior family arguments over health care decisions may be primed for ACP.

Context Preliminary trials report that Scrambler Therapy, a form of electroanalgesia, may improve discomfort from chemotherapy-induced peripheral neuropathy (CIPN). Objective The objective of this phase II, randomized controlled trial was to evaluate the efficacy of Scrambler therapy vs. transcutaneous electrical nerve stimulation (TENS) in treating CIPN. Methods Fifty patients were accrued for the first half of this two-part, crossover trial consisting of a 2-week treatment period with either Scrambler or TENS, followed by an 8-week observation period, and then crossover treatment. Twenty-two patients proceeded to the crossover phase. The primary means of assessment was patient-reported outcomes, including symptom severity scales and Global Impression of Change questionnaires. Symptoms were assessed daily during the treatment period and weekly during an 8-week observation period. Results A 50% or greater reduction in primary symptom (pain or tingling) score on the last day of treatment was achieved by 6 of 10 Scrambler-treated patients (60%) and 3 of 12 TENS-treated patients (25%) after crossover (P = 0.11). By day 4 of treatment, the two arms diverged with respect to mean change in primary symptom score; this effect was largely carried through to the end of the two-week treatment period. Similarly, Scrambler therapy appeared better than TENS when assessed by Global Impression of Change for neuropathy, pain, and overall quality of life. Conclusions Similar findings from the initial randomization and crossover phases of this study support further evaluation of the efficacy of Scrambler therapy in alleviating CIPN symptoms. Evaluation in a larger, randomized controlled trial with standardized treatment is warranted.

Immune checkpoint inhibitors (ICIs) have opened an exciting chapter in the treatment of patients with advanced cancer. For the palliative care clinician, however, ICIs present several new challenges, including new ways to define treatment success, as well as treatment-related toxicities that differ in nature and timing from traditional chemotherapy. In this article, we review the mechanism of action of ICIs, as well as selected published data supporting the efficacy of ICIs in patients with advanced cancer. In addition, we summarize existing data of ICI toxicity prevalence, patterns of severity, and timing of onset. Finally, we briefly review key principles from published guidelines on the management of ICI toxicities.

Context Patients with advanced cancer often worry about dying. Less is known about the role of worry in decision making regarding future care. Objectives To explore relationships between patients' worry about dying and their illness understanding, treatment preferences, and advance care planning (ACP). Methods This cross-sectional study used baseline data from a primary palliative care intervention trial. All participants had metastatic solid tumors. Using patients' response to I worry about dying from the Functional Assessment of Chronic Illness—Palliative Care survey instrument, univariate and multivariate analyses assessed associations with illness understanding, treatment preferences, and ACP. Results Of 672 patients, 47% reported worrying about dying not at all, whereas 9.7% worried quite a bit or very much. In regression analysis, compared with patients who reported not worrying about dying, those who reported high levels of worry were more likely to describe themselves as terminally ill (adjusted odds ratio [AOR] = 1.98; 95% CI = 1.10–3.54; P = 0.021) and prefer life-extending therapy over symptom-focused care (AOR = 2.61; 95% CI = 1.30–5.22; P = 0.007). They were less likely to have completed an advance directive (AOR = 0.49; 95% CI = 0.25–0.94; P = 0.032). The same relationships were seen using patients' response to I feel scared about my future from the Herth Hope Index. Conclusion Patients with advanced cancer who worry about dying are more likely to identify as terminally ill and desire life-extending treatment and are less likely to engage in ACP. Understanding how patients cope with worry and make medical decisions is important in providing quality care to these patients.

Context Advance care planning rates remain low, especially among people who are HIV positive, disadvantaged, and African American. Although advance care planning can be a sensitive topic for clinicians and patients to discuss, health values clarification can be an important initial step. Objectives The purpose of the study was to explore health values of African Americans living with HIV/AIDS and to examine correlates of these values. Methods Data were from the first 325 participants in the AFFIRM Care study, which enrolled adults living with HIV/AIDS in Baltimore, Maryland, who had histories of illicit drug use. Respondents were asked whether (yes/no) they thought any of six health states would be worse than death: severe unremitting pain, total dependency on others, irreversible coma, being on mechanical ventilation, nursing home residence, and severe dementia. Latent class analysis was used to group individuals by their pattern of responses, interpretable as preference for aggressive (life-sustaining) or nonaggressive (palliative) end-of-life care. Latent class regression analysis was used to examine associations between class membership and background, health status, and social variables. Results We found statistical support for a three-class latent class analysis model: 1) the nonaggressive treatment class, comprising 43% of cases, in which members perceived that every state was worse than death; 2) the aggressive treatment class, comprising 33% of cases, in which members perceived that none of the states was worse than death; and 3) the mixed class (24% of cases), in which members perceived that only four of the six states were worse than death. Conclusion Three-quarters of participant response patterns had clear preferences for treatment decisions. Further research is needed to ensure inclusion of end-of-life scenarios relevant to this population.

Therapeutic hypothermia (ARCTIC, or Advanced Resuscitation Cooling Therapeutics and Intensive Care protocol) is a widely recommended intervention to improve mortality and neurologic outcomes after cardiac arrest. However, neurologic outcomes are difficult to predict soon after cardiac arrest in the setting of hypothermia, as illustrated by this case report. A 60-year-old man had witnessed cardiac arrest at home. He was defibrillated twice, with return of spontaneous circulation, and cooled to 33°C for 24 hours. Neurologic exam on Day 6 revealed limited brainstem reflexes, and the intensive care unit team discussed with the patient's family that his prognosis for neurologic recovery was poor. Palliative care was consulted to participate in a goals-of-care meeting. Just prior to the meeting on Day 7, the patient awoke. He fully recovered and walked out of the hospital on Day 18. Prior to induced hypothermia, indicators of poor outcome included lack of one or more brainstem reflexes (pupillary or corneal reflex), absence of motor response at 72 hours, myoclonus, status epilepticus, electroencephalogram with generalized suppression, and absent bilateral cortical N20 response to somatosensory-evoked potentials. However, several studies have found these indicators to be unreliable after hypothermia. This may be the result of sedatives, which can affect physical examination and electroencephalogram results, and delayed clearance. Because of the unreliability of prognostication tests within the first 72 hours of hypothermic protocols in the setting of sedation, it appears prudent in some cases to delay final prognosis discussions until at least six days postcardiac arrest and after neurologic evaluation is done with patients sedative-free.

Context. Chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting and persistent consequence of numerous classes of antineoplastic agents, affecting up to 30%e40% of patients. To date, there is no effective prevention or therapy. An evolving hypothesis for reducing CIPN pain involves direct nerve stimulation to reduce the pain impulse. Objectives. To evaluate the impact on CIPN associated with the MC5-A Calmare therapy device (Competitive Technologies, Inc. Fairfield, CT). Methods. The MC5-A Calmare therapy device is designed to generate a patient-specific cutaneous electrostimulation to reduce the abnormal pain intensity. Sixteen patients from one center received one-hour interventions daily over 10 working days. Results. Of 18 patients, 16 were evaluable. The mean age of the patients was 58.6 yearsdfour men and 14 womendand the duration of CIPN was three months to eight years. The most common drugs were taxanes, platinums, and bortezomib (Velcade, Millenium Pharmaceuticals, Cambridge MA). At the end of the study (Day 10), a 20% reduction in numeric pain scores was achieved in 15 of 16 patients. The pain score fell 59% from 5.81 � 1.11 before treatment to 2.38 � 1.82 at the end of 10 days (P < 0.0001 by paired t-test). A daily treatment benefit was seen with a strong statistically significant difference between the preand post-daily pain scores (P < 0.001). Four patients had their CIPN reduced to zero. A repeated-measures analysis using the scores from all 10 days confirmed these results. No toxicity was seen. Some responses have been durable without maintenance. Conclusions. Patient-specific cutaneous electrostimulation with the MC5-A Calmare device appears to dramatically reduce pain in refractory CIPN patients with no toxicity. Further studies are underway to define the benefit, mechanisms of action, and optimal schedule. J Pain Symptom Manage 2010;-:-e-. 2010 Published by Elsevier Inc on behalf of U.S. Cancer Pain Relief Committee.

Although palliative care is rarely profitable by itself, palliative care in hospitals is associated with significant reductions in per diem costs and total costs, and can generate substantial savings to the health system by "cost avoidance." Palliative care alongside usual care in recent randomized outpatient trials has maintained or improved the quality of care while generating substantial cost savings. The data are mixed about the impact of palliative care consultation on inpatient length of stay and are related to local patterns of care, consultation, and assumption of control of the course of care. In collecting and presenting the data to administrators and others, we have found that the simplest approach is the most effective—for example, presenting a few clinical outcomes alongside cost-saving data.

Dyspnea, a subjective symptom of impaired breathing, occurs in 70% of terminally ill cancer patients. Current treatments are suboptimal and little is known about the patient's perception of effect. We tested nebulized inhaled fentanyl citrate on patient perceptions, respiratory rate, and oxygen saturation. The study was conducted using a convenience sample of 35 cancer patients on a dedicated oncology unit. We assessed patient perception (did breathing stay the same, worsen, or improve), respiratory rate, and oxygen saturation by pulse oximetry at baseline, 5 minutes, and 60 minutes. Twenty-six of 32 (81%) patients reported improvement in breathing, 3 (9%) were unsure, and 3 (9%) reported no improvement. Oxygen saturation improved from 94.6% at baseline to 96.8% at 5 minutes and 96.7% at 60 minutes (P = 0.0069 compared to baseline). Respiratory rates improved from a baseline of 28.4/min to 25.9/min at 5 minutes and 24.1/min at 60 minutes (P = 0.0251 compared to baseline). No side effects were observed. Inhaled nebulized fentanyl citrate significantly improved patient perception of breathing, respiratory rate, and oxygen saturation. This inexpensive and readily available treatment may offer substantial relief of end-of-life dyspnea. Randomized trials, dose, and length of effect trials are underway.

Context The topical gel known as "ABH gel," comprising lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®), is frequently used to treat nausea because of its perceived efficacy, relatively low cost, and ease of use in the home setting. There are limited scientific data on this medication, however. Recent pilot studies showed no absorption of the active ingredients of the gel, prompting further prospective studies into the cause of the perceived efficacy in the clinical setting. Objectives To determine any difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. Methods A randomized, double-blind, placebo-controlled, crossover, noninferiority clinical trial was developed to test the hypothesis that there is no difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. The primary outcome was the difference in nausea score (on a 0–10 scale) at baseline and at 60 minutes in each treatment group. The difference in the ABH gel-treated group compared with placebo was evaluated for noninferiority. Secondary outcomes included the number of vomiting episodes and side effects over time. Results The mean change in nausea score from baseline to 60 minutes after treatment in the ABH gel group was 1.7 ± 2.05 and 0.9 ± 2.45 for the placebo group (P = 0.42). The placebo group was found to be noninferior to the ABH gel group in reducing the nausea score. ABH gel also did not decrease vomiting events better than placebo (P = 0.34). Only one patient reported any side effects from the treatments in either arm of the study. Conclusion ABH gel in its current formulation should not be used in cancer patients experiencing nausea.

Rebecca Aslakson, MD PhD, Johns Hopkins Hospital, Baltimore, MD Arif Kamal, MD, Duke Cancer Institute, Durham, NC Laura Gelfman, MD, Mount Sinai Hospital, New York, NY Polly Mazanec, PhD ACNP-BC FPCN, Cleveland Veterans Affairs Medical Center, Cleveland, OH R. Sean Morrison, MD FAAHPM, Icahn School of Medicine at Mount Sinai, New York, NY Betty Ferrell, PhD RN MA FAAN FPCN CHPN, City of Hope Medical Center, Duarte, CA Joann N. Bodurtha, MD MPH FAAP FACMG, Johns Hopkins University, Baltimore, MD Amy Abernethy, MD FAAHPM, Duke University Medical Center, Durham, NC Thomas J. Smith, MD FAAHPM, Johns Hopkins Hospital, Baltimore, MD

with beneficence. Research Objectives: communication strategies in conversations where do-not-resuscitate (DNR) status is discussed. Methods: Semistructured in-depth interviews were conducted with 29 internal medicine doctors across two sites in the United States who were routinely involved in DNR conversations with patients at the end of life. Participants were purposely sampled by stage of training and medical subspecialty to provide a wide range of perspectives and contribute to understanding emerging patterns and themes. Interviews lasted 60 minutes on average and were audiotaped and transcribed. Transcripts were analyzed and double coded using thematic analysis with an interpretive approach. Results: Experienced doctors at all sites generally felt comfortable engaging in shared decision making and, when clinically appropriate, making more paternalistic recommendations against resuscitation. However, residents and fellows felt less comfortable restricting choice and felt compelled to offer choice even if the chance of successful resuscitation was negligible

Overuse or misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation's Choosing Wisely® campaign is a multiyear effort to encourage physician leadership in reducing harmful or inappropriate resource utilization. Via the campaign, medical societies are asked to identify five tests or procedures commonly used in their field, the routine use of which in specific clinical scenarios should be questioned by both physicians and patients based on the evidence that the test or procedure is ineffective or even harmful. The American Academy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed to participate in the campaign. The AAHPM Choosing Wisely Task Force, with input from the AAHPM membership, developed the following five recommendations: 1) Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care; 4) Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis; and 5) Don't use topical lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®) (ABH) gel for nausea. These recommendations and their supporting rationale should be considered by physicians, patients, and their caregivers as they collaborate in choosing those treatments that do the most good and avoid the most harm for those living with serious illness.

care. The presentation will then review current palliative care bills and legislative and executive branch priorities, including the champions, sponsors, and coalitions supporting them. In addition, since much of the real policy action is outside of Washington, the presentation will review important state efforts to provide examples other states may want to consider. Participants will also gain information on how to participate in policy on a local, state, and national level, including tips on how to best position palliative care as a key solution within healthcare reform. The role and value of coalitions in this area also will be reviewed.

Background Lorazepam (Ativan ® ), diphenhydramine (Benadryl ® ), haloperidol (Haldol ® ) (ABH) topical gel is currently widely used for nausea in hospice because of perceived efficacy and low cost and has been suggested for cancer chemotherapy. However, there are no studies of absorption, a prerequisite for effectiveness. We completed this study to establish whether ABH gel drugs are absorbed, as a prerequisite to effectiveness. Intervention Ten healthy volunteers, aged 25 to 58 years (mean 37 years), two African Americans and eight Caucasian Americans, applied the standard 1.0mL dose (2mg of lorazepam, 25mg of diphenhydramine, and 2mg of haloperidol in a pluronic lecithin organogel), rubbed on the volar surface of the wrists by the subject. Measures Blood samples were obtained at 0, 30, 60, 90, 120, 180, and 240 minutes. Plasma concentrations were analyzed by liquid chromatography-tandem mass spectrometry using deuterated internal standards for each drug. Outcomes No lorazepam or haloperidol was detected in any sample from any of the 10 volunteers down to a level of 0.05ng/mL. Diphenhydramine was found in multiple plasma samples at concentrations >0.05ng/mL in three patients, with the highest concentration of 0.30ng/mL in one person at 240 minutes. Overall, five of 10 patients exhibited detectable diphenhydramine in one or more samples, supporting limited absorption. No subject noted any side effects. Conclusions/Lessons Learned As commonly used, none of the lorazepam, haloperidol, or diphenhydramine in ABH gel is absorbed in sufficient quantities to be effective in the treatment of nausea and vomiting. Diphenhydramine is erratically absorbed at subtherapeutic levels. The efficacy of ABH gel should be confirmed in randomized trials before its use is recommended.

Objectives 1. Identify the need for communication skills assessment tools for the Accreditation Council for Graduate Medical Education Next Accreditation System. 2. Define specific communication skills and the essential dimensions of each skill. 3. Utilize the communication skills assessment tool to identify communication skills and provide formative feedback; delineate other uses for the communication skills assessment tool, including its potential use with other levels of learners (eg, residents, medical students). Advancing communication skills is a core component of hospice and palliative medicine fellowship training. Emerging evidence suggests that discussions with patients and families about the patient’s prognosis and plan of care, led by expert skilled communicators, result in improved outcomes. Because communication skills are critical for medical trainees, communication skills assessment is central to the American College of Graduate Medical Education’s (ACGME) Next Accreditation System (NAS). This session will train palliative care faculty to evaluate trainees’ communication skills using a direct, real-time family meeting observation tool. In this session, we will present background on the need for communication skills assessment for hospice and palliative medicine fellowship programs within the context of the NAS. We will define the communication skills used commonly in the fields of hospice and palliative medicine and present the essential dimensions of each skill. In addition, we will orient the participants to FaMCAT, the newly developed, realtime direct observation communication skills assessment tool, and present the data on its feasibility, reliability, evaluator satisfaction, and ease of identification of areas for further training. We will link FaMCAT to NAS proposed competencies in communication. Next, we will train participants in communication skills assessment with FaMCAT using a mock family meeting. While observing the mock family meeting, the participants will complete the assessment tool. We will then break into four small groups, with one panel member moderating each group, and review the FaMCAT to reach consensus on the identification of each communication skill. Finally, we will demonstrate how using this tool will allow educators to provide formative feedback and need-based training, a NAS core principle. We will also provide time for a discussion of other potential uses for FamCAT, including the benefits and barriers to its use with other learners, including residents and medical students.

Context. Neuropathic pain is common, disabling, and often difficult to treat. Objectives. To compare guideline-based drug management with Scrambler therapy, a patient-specific electrocutaneous nerve stimulation device. Methods. A clinical trial with patients randomized to either guideline-based pharmacological treatment or Scrambler therapy for a cycle of 10 daily sessions was performed. Patients were matched by type of pain including postsurgical neuropathic pain, postherpetic neuralgia, or spinal canal stenosis. Primary outcome was change in visual analogue scale (VAS) pain scores at one month; secondary outcomes included VAS pain scores at two and three months, pain medication use, and allodynia. Results. Fifty-two patients were randomized. The mean VAS pain score before treatment was 8.1 points (control) and 8.0 points (Scrambler). At one month, the meanVASscorewasreducedfrom8.1to5.8(� 28%)inthecontrolgroup,andfrom 8 to 0.7 points (� 91%) in the Scrambler group (P< 0.0001). At two and three months, the mean pain scores in the control group were 5.7 and 5.9 points, respectively, and 1.4 and 2 points in the Scrambler group, respectively (P< 0.0001). More relapses were seen in polyradicular pain than monoradicular pain, but retreatmentandmaintenancetherapygaverelief.Noadverseeffectswereobserved. Conclusion. In this pilot randomized trial, Scrambler therapy appeared to relieve chronic neuropathic pain better than guideline-based drug management. J Pain Symptom Manage 2012;43:87e95. 2012 U.S. Cancer Pain

Context Using mortality rates to measure hospital quality presumes that hospital deaths are medical failures. To be a fair measure of hospital quality, hospital mortality measures must take patient-level factors, such as goals of care, into account. Objectives To answer questions about how hospital mortality rates are computed and how the involvement of hospice or palliative care (PC) are recognized and handled. Methods We analyzed the methods of four entities: Centers for Medicare & Medicaid Services "Hospital Compare;" U.S. News & World Report "Best Hospitals;" Thomson-Reuters "100 TopHospitals;" and HealthGrades. Results All entities reviewed rely on Medicare data, compute risk-adjusted mortality rates, and use "all-cause" mortality. They vary considerably in their recognition and handling of cases that involved hospice care or PC. One entity excludes cases with prior hospice care and another excludes those discharged to hospice at the end of the index hospitalization. Two entities exclude some or all cases that were coded with the V66.7 "Palliative Care Encounter" International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code. Conclusion Proliferation of, and variability among, hospital mortality measures creates a challenge for hospital administrators. PC and hospice leaders need to educate themselves and their hospital administrators about the extent to which these mortality rates take end-of-life care into account. At the national level, PC and hospice leaders should take advantage of opportunities to engage these mortality raters in conversation about possible changes in their methods and to conduct further research on this topic.

Identify tools that can help one recognize genetic issues, refer for counseling, and suggest DNA banking or testing. Recognize practical ways to donate a body to science in most states. Genetics, epigenetics, and genomics all play an increasingly recognized role in disease causation and progression. While upstream recognition of genetic-related serious illness is always preferable, an estimated 10% of patients dying in hospice or palliative care will have previously unrecognized genetic causes. The benefits of timely recognition and appropriate action—often right before the person dies—include offer of discussion about at least one the following: (a) saving appropriate DNA or other specimens from the person with the condition for future testing, before that opportunity is lost; (b) genetic counseling and testing for changes such as BRCA, Lynch syndrome, or cardiomyopathy; (c) counseling of the remaining family; or (d) being part of legacy or life review. We will illustrate the possible actions to take with three cases: a 41-year-old woman presenting near death with advanced colon cancer; a 53-year-old man with congestive heart failure, three of whose four siblings have died from heart failure or had heart transplants; and a 55-year-old woman with dementia.

Research Objectives. The goal of this research was to pilot-test a tool to assess the range of transitions experienced by patients with cancer: the Measurement of Transitions (MOT) instrument. The only other measure of transitions focuses on transitions between care settings. Method. As part of a larger one-group, pre-post test study testing a self-management intervention, patients with breast cancer completed the MOT at a chemotherapy clinic. Two 10-point Likert scales were offered for each of seven transitions identified in previous work: physical; emotional; social; spiritual; cancer status; treatment; and approach to care (curative/palliative/hospice). Respondents first rated the degree of change they experienced for each transition and then how well they dealt with each change. Cognitive interviews, which assess how individuals interpret survey items, followed. Content analysis was used to analyze interview data.

Increasing numbers of patients with refractory pain are receiving intrathecal drug delivery systems (IDDS). We describe a case to illustrate the clinical manifestations and management implications of inadvertent overdose with drugs used in IDDS, including opioids, clonidine, baclofen, and local anesthetics. An IDDS patient received a bimonthly dose of intrathecal hydromorphone subcutaneously. The patient received a total of 540 mg hydromorphone into the subcutaneous pocket around the intrathecal pump. She was treated with naloxone intravenously over 12 hours, and had no major adverse sequelae. Such occurrences may happen more frequently with the expanded use of IDDS and clinicians should be prepared to take quick action. Counteracting an opioid with naloxone until the opioid is metabolized and excreted can be done safely. Inadvertent subcutaneous administration of other types of drugs could be more difficult to manage.

medicine physicians are accused of hastening a patient’s death. Methods. We conducted an Internet-based survey on a random 50% sample of physician members of a national palliative medicine professional society. Subjects were contacted by e-mail and if they didn’t respond, they were then contacted by regular mail. Results. After correcting for unreachable or ineligible subjects, the final sample consisted of 663 physicians (response rate 53.5%). Fifty-five percent of respondents were male, and the median age was 50 years.When asked which actionsmight be misperceived as hastening death, subjects rated palliative sedation as the most risky, followed by stopping artificial hydration/nutrition. When asked if over the last five years anyone had characterized a palliative treatment provided by the respondent as ‘‘euthanasia’’ or ‘‘murder,’’ 25% answered that a patient had done so, 60% reported that a patient’s friend or family had, and 55% reported another physician had stated this. Overall, 25 subjects (3.8%) had been formally investigated for hastening a patient’s death. In 13 of these, using opioids for symptom treatment was the source of the investigation, and in six investigations it was medications used while discontinuing mechanical ventilation. Fourteen accused physicians had been cleared of charges, investigations were ongoing in five, and none were found guilty. Conclusion. About 4% of physician-respondents had been formally investigated for hastening a patient’s death. Behaviors physicians consider the most risky are different than those for which they are most commonly investigated. Implications for research, policy, or practice. By understanding more about when and why physicians were formally accused, clinicians may be able to change their practice to reduce their risk of being perceived as hastening a patient’s death.

services and hospitalizations and ineffective and burdensome interventions and less likely to utilize palliative care. The success of health system reform depends largely on the capacity of seriously ill patients from diverse backgrounds to make informed decisions about their health and health care. In this immersion learning session, we will utilize a variety of multimedia tools and exercises to gain an experiential understanding of the concepts of limited health literacy and numeracy and the communication challenges they pose to all palliative care clinicians. Next, we will identify two concrete strategies to better assess and manage persons with limited literacy and thereby promote better informed decision making and easier access to palliative care for these patients and their families.

opioids. Reason 7: Buprenorphine is not immunosuppressive like morphine and fentanyl. Reason 8: Buprenorphine does not reduce hypothalamic gonadotropins axis or cause hypogonadism. Reason 9: Buprenorphine does not prolong the QTc interval and is associated with fewer sudden deaths than methadone. Reason 10: Buprenorphine is a safe and effective analgesic for the elderly. Reason 11: Buprenorphine is the one of the safest opioid to use in renal failure and for individuals on dialysis. Reason 12: Withdrawal symptoms are milder with buprenorphine and drug dependence is less. In light of the evidence for its efficacy, safety, versatility, and cost, buprenorphine should be considered as a first line analgesic. This concurrent session will start with a patient presentation followed by a review of the benefits of and some of the problems with using buprenorphine.

An elderly wife and mother dying of end-stage cardiomyopathy who experienced significant distress about her dying process. Her acute dying process was prolonged, and her family compellingly requested help from the palliative care team with hastening her death. Using an interactive format with audience participation and discussion, we will discuss the pearls learned from our ‘‘bucket list’’ patients and briefly review supporting evidence.

Effective Treatment of Post-Herpetic Neuropathy With Scrambler Therapy, Patient-Specific Neurocutaneous Electrical Stimulation (311-C) Thomas Smith, MD, Johns Hopkins Health System, Baltimore, MD. Giuseppe Marineo University of Rome Tor Vergata, Rome Italy. Patrick Coyne, MSN APRN FAAN, Virginia Commonwealth University, Richmond, VA. Patricia Dodson, MA BSN RN CCRC, Virginia Commonwealth University, Richmond, VA. (All authors listed above for this session have disclosed no relevant financial relationships with the following exception: Marineo received a royalty from CTTC for his role in intellectual property (patent).)

Specialist palliative care (PC) often embraces a “less is more” philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC.