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Background: Optimal pain management in the palliative care setting often requires multiple pharmacological interventions including novel and off-label therapies. Ketamine is an anesthetic agent with increasing evidence supporting its use for pain. Through N-methyl-d-aspartate antagonism and activity at opioid receptors, it is an adjuvant to traditional analgesics with the benefit of being opioid sparing. Ketamine has a wide safety profile with limited reports of overdose. Little is published on supratherpeutic dosing in the pain setting. Objective: We report a case of a 41-year-old male with refractory nociceptive and neuropathic cancer-related pain. Conventional therapies were ineffective. Ketamine was initiated to reduce opioid burden and attenuate pain with good response. The patient received an iatrogenic overdose (10 times ordered dose) of the drug. Several self-limited physiologic and psychologic reactions were observed during subsequent monitoring. Design: This is a study and analysis of a patient with refractory nociceptive and neuropathic pain syndrome treated with ketamine who sustained an iatrogenic overdose of ketamine. Conclusions: Ketamine's use to treat pain is increasing along with its evidence of efficacy. Despite ketamine's wide safety profile, the medication is not without risk, especially in palliative care wherein patients are on multiple drugs with potentially severe interactions. Careful examination of the risks of overdose, especially of the various formulations of the drug, is needed.

Palliative care consultation has been demonstrated to be useful in many situations in which expert symptom management, communication around sensitive issues, and family support may serve to enhance or improve care. The process of organ donation is an example of this concept, specifically the process of donation after cardiac death (DCD). DCD allows patients with severe, irreversible brain injuries that do not meet standard criteria for brain death to donate organs when death is declared by cardiopulmonary criteria. The DCD method of donation has been deemed an ethically appropriate means of organ donation and is supported by the organ procurement and medical communities, as well as the public. The palliative care (PC) team can make a significant contribution to the care of the patient and family in the organ donation process. In this paper we describe the controlled DCD process at one institution that utilizes the PC team to provide expert end-of-life care, including comprehensive medical management and family support. PC skills and principles applicable to the DCD process include communication, coordination of care, and skillful ventilator withdrawal. If death occurs within 90 minutes of withdrawal of life support, organs may be successfully recovered for transplantation. If the patient survives longer than 90 minutes, his or her care continues to be provided by the PC team. Palliative care can contribute to standardizing quality end-of-life care practices in the DCD process and provide education for involved personnel. Further experience, research and national discussions will be helpful in refining these practices, to make this difficult and challenging experience as gentle and supportive as possible for the courageous families who participate in this process.

Current end-of-life hospital care can be of poor quality and high cost. High volume and/or specialist care, and standardized care with clinical practice guidelines, has improved outcomes and costs in other areas of cancer care.The objective of this study was to measure the impact of the palliative care unit (PCU) on the cost of care. The PCU is a dedicated 11-bed inpatient (PCU) staffed by a high-volume specialist team using standardized care. We compared daily charges and costs of the days prior to PCU transfer to the stay in the PCU, for patients who died in the first 6 months after the PCU opened May 2000. We performed a case-control study by matching 38 PCU patients by diagnosis and age to contemporary patients who died outside the PCU cared for by other medical or surgical teams, to adjust for potential differences in the patients or goals of care.The unit admitted 237 patients from May to December 2000. Fifty-two percent had cancer followed by vascular events, immunodeficiency, or organ failure. For the 123 patients with both non-PCU and PCU days, daily charges and costs were reduced by 66% overall and 74% in "other" (medications, diagnostics, etc.) after transfer to the PCU (p0.0001 for all). Comparing the 38 contemporary control patients who died outside the PCU to similar patients who died in the PCU, daily charges were 59% lower (US dollars 5304 +/- 5850 to US dollars 2172 +/- 2250, p = 0.005), direct costs 56% lower (US dollars 1441 +/- 1438 to US dollars 632 +/- 690, p = 0.004), and total costs 57% lower (US dollars 2538 +/- 2918 to US dollars 1095 +/- 1153, p = 0.009).Appropriate standardized care of medically complex terminally ill patients in a high-volume, specialized unit may significantly lower cost. These results should be confirmed in a randomized study but such studies are difficult to perform.

Prostacyclin analogues such as epoprostenol (Flolan®) are commonly used in the treatment of pulmonary arterial hypertension (PAH). However, their complex administration and significant cost may limit the access that patients with PAH have to palliative and hospice care. We herein report our experience using epoprostenol in a dedicated palliative care unit and present our inpatient protocol for the drug's administration.

Donation after cardiac death (DCD) or donation of organs after removal of life support is an accepted means of organ retrieval that usually occurs in the setting of sudden illness but has not been described in people with progressive neurologic illness. We report DCD in two people with progressive amyotrophic lateral sclerosis (ALS).Case series at an academic medical center of two men with progressive ALS who underwent withdrawal of artificial life support, rapid cardiac death, and subsequent organ donation. The primary outcome was donation of organs in concordance with patient and family wishes.Both patients underwent peaceful withdrawal of life support in the presence of family, and multiple organs were donated.Patients may legally and ethically refuse life-sustaining care. These patients considered their lives to be more burdensome than beneficial near the end of their lives, both carefully planned the time and circumstance of their deaths, and both fulfilled a long-standing desire to donate their organs. This study describes a potential opportunity for patients with progressive neurologic illness.

Dexmedetomidine (Precedex®) is an alpha-2 adrenergic agonist that can produce sedation and analgesia without causing respiratory depression. Its use has been described in patients undergoing mechanical ventilation, sedation for surgical and nonsurgical procedures, and prevention of withdrawal. We describe its use as an adjuvant analgesic in a patient with cancer pain refractory to multiple treatment modalities.

Palliative care provides open and honest communication, medically appropriate goal setting, and meticulous attention to symptom assessment and control. The Physicians Orders for Life Sustaining Treatment (POLST) is a growing movement to allow health care providers to indicate, with their patients, what they want done in specific situations, such as feeding tubes, mechanical ventilation, or transfer to an intensive care unit. We have developed an internal signout tool used by palliative medicine fellows in our institution to specify similar interventions-or not-with seriously ill palliative care patients, the Providers Signout for Scope of Treatment (PSOST). We have found that this situation-specific tool enables smooth transitions of care on nights and weekends, especially when the patient is near death, and may help prevent both overescalation of care and underuse of life saving treatments such as resuscitation. The PSOST differs from other signout tools in that it gives clear direction regarding the patient's medical goals and desire for escalation of care, or not. We present it here for open access and use anywhere. This tool has also assisted in building team communication with the nursing shifts, especially nights and weekends, as all team members are able to deliver a consistent message, while meeting the goals of care for patients and families. We believe this tool could be useful with a broader patient population, outside of Palliative Medicine, to provide clearer direction for hospitalized or nursing home patients whose care is often directed by multiple providers. It could also be used as a template for signouts on other inpatient services, as care goals are important for all patients.

Introduction: We studied the impact of an 11-bed inpatient palliative care unit (PCU) on site of death and observed mortality in the health system, oncology, and palliative care units. Observers were concerned that an active PCU would attract dying patients and worsen comparative mortality rates for Medicare and U.S. News & World Report comparisons. Methods: We reviewed 10 years of experience with all patients who died in the hospital before and after we opened our PCU in 2000. Results: The PCU concentrated dying patients on the PCU but total deaths did not change over 10 years and remained approximately 3% of admissions. Within 2 years, one quarter of all health system decedents died on the PCU. The proportion who died on the oncology floor and general units declined, but the number of intensive care unit deaths did not change. Conclusions: An inpatient PCU did not increase the hospital-wide death rate. The PCU did change the site of death to a more appropriate venue for one quarter of patients.

Palliative care is growing in the United States but little is known about the quality of care delivered.To benchmark the quality of palliative care in academic hospitals.Multicenter, cross-sectional, retrospective chart review conducted between October 1, 2002 and September 30, 2003.Thirty-five University HealthSystem Consortium (UHC) academic hospitals across the United States.A total of 1596 patient records.(1) adults, (2) high-mortality diagnoses: selected cancers, heart failure, human immunodeficiency virus (HIV), and respiratory conditions requiring ventilator support, (3) length of stay (LOS) more than 4 days, and (4) two prior admissions in the preceding 12 months.Compliance with 11 key performance measures (KPM) derived from practice standards, literature evidence, and input from a multidisciplinary expert committee. Analyses examined relationships between provision of the KPM and specific outcomes.Wide variability exists among academic hospitals in the provision of the KPM (0%-100%). The greater the compliance with KPM, the greater the improvement in quality outcomes, cost and LOS. Assessment of pain (96.1%) and dyspnea (90.2%) was high, but reduction of these symptoms was lower (73.3% and 77.2%). Documentation of prognosis (33.4%), psychosocial assessment (26.2%), communication with family/patient (46%), and timely planning for discharge disposition (53.4%) were low for this severely ill population (16.8% hospital mortality). Only 12.9% received a palliative care consultation.The study reveals significant opportunities for improvement in the effective delivery of palliative care. Care that met KPM was associated with improved quality, reduced costs and LOS. Institutions that benchmarked above 90% did so by integrating KPM into daily care processes and utilizing systematized triggers, forms and default pathways. The presence of a formalized palliative care program within a hospital system had a positive effect on the achievement of KPM, whether or not formal consultation occurred. Hospitals need to develop systematic methods to improve access to palliative care.

A randomized clinical trial of implantable drug delivery system (IDDS) plus comprehensive medical management (CMM) versus CMM alone in 200 patients with refractory cancer pain showed better clinical success with IDDS. The objective of this study was to evaluate whether IDDS could help the most refractory patients failed by expert CMM.This was a planned longitudinal prospective analysis of 30 of 99 (30%) patients for whom CMM failed who crossed over to IDDS by 6 months, as part of the randomized clinical trial. Patients had a pain visual analogue scale (VAS) score of 5 or more despite CMM with 320 mg or morphine-equivalent opioids and adjunct drugs for 1 month. The intervention was an implantable intrathecal programmable pump with opioids and local anesthetics. Clinical success was measured as a 20% change in pain VAS score and NCI CTEP drug toxicity scales.Clinical success was achieved with pain scores and drug toxicity scores significantly reduced by 27% (p = 0.011) and 51% (p0.0001). Median survival was 103 days after IDDS implant, similar to IDDS patients who received implantation as part of the initial randomization.CMM patients who crossed over to IDDS for the most refractory pain had significant reductions in pain and drug toxicity. The survival time of 3 months may be long enough for the IDDS implant to be cost effective. In this prospective longitudinal study, patients with refractory cancer pain despite comprehensive medical management derived benefit from IDDS.

769 END-OF-LIFE CARE (EOL) within our society today is often fragmented. Improvement in the quality of life for this vulnerable population of individuals with unique needs requires a highly skilled and knowledgeable team of practitioners. Nurses, more than other health care professionals, are on the frontline as caregivers for individuals facing the end of life.1,2 Advanced practice nurse (APN) roles are numerous and extremely varied depending on the settings and needs of the populations to be served.3 The American Nurses Association (ANA) notes, “the Advanced Practice Registered Nurse integrates education, research, management, leadership and consultation into clinical roles and they function in collegial relationships with nursing peers and other professionals and individuals who influence the environment.”4 The APN must have highly evolved clinical and communication skills as well as attentive planning and coordination efforts. The clinical skills that this individual must possess allow for more frequent and comprehensive palliation in any setting. The APN is complementary to, rather than competitive with, the physician as both collaborate to meet the needs of this complex population. Certification in palliative care for APNs is now available. The End of Life Nursing Education Consortium, (ELNEC) has recently developed a program to educate faculty of graduate nursing students in EOL care, demonstrating that there is currently high interest in this field. APNs are uniquely qualified to expand their roles into the palliative care arena. Utilizing the ANA description of the categories incumbent on this position might demonstrate potential opportunities for APNs within our health care systems. EDUCATION