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Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann–Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals. [ABSTRACT FROM AUTHOR]

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration. [ABSTRACT FROM AUTHOR]

Objective: Latinos are disproportionately affected by diabetes and people with diabetes experience frequent hospital admissions and readmissions. Care transition interventions can help reduce rates of readmission; however, there are many barriers to recruiting Latinos for participation in intervention research. Exploring reasons for study refusal furthers understanding of low research participation rates to help researchers address barriers. Design: This study presents a cross-sectional, descriptive analysis of reasons for study refusal and attrition drawing from data collected as part of a randomized controlled trial conducted to test the effectiveness of a transitions intervention for diabetic Latino discharged from the hospital to home. Reasons for refusal were elicited from participants, transcribed, and coded. Descriptive statistics and bivariate analyses were used to compare those who completed the study and those who did not complete the study. Results: Reasons for study enrollment refusal and loss to follow-up ranged from difficulty locating the patient to homelessness to patient reluctance to having providers in the home. Study completers were more likely than non-completers to reside with family members (p = .03) and have a spouse as a primary caregiver (p = .08). Conclusions: Inner city, monolingual Latinos may be difficult to enroll and engage in home-based interventions. Although not representative of all Latino populations, barriers encountered highlight the need for targeted research to improve transitional care among Latinos. Researchers and clinicians should take into consideration the unique barriers that Latinos face in participating in research and intervention studies. [ABSTRACT FROM PUBLISHER]

Context: Given recent Medicare rules reimbursing clinicians for engaging in advance care planning, there is heightened need to understand factors associated with the timing of advance directive (AD) completion before death and how the timing impacts care decisions.Objective: The purpose of this study was to investigate patterns in timing of AD completion and the relationship between timing and documented care preferences. We hypothesize that ADs completed late in the course of illness or very early in the disease trajectory will reflect higher preferences for aggressive care.Methods: We conducted a retrospective study using logistic regressions to analyze data from the Health and Retirement Study, a nationally representative longitudinal survey of older adults.Results: The analytic sample included exit interviews conducted from 2000 to 2012 among 2904 proxy reporters of deceased participants who had an AD. Nearly three-quarters (71%) of ADs were completed a year or more before death. Being younger or a racial/ethnic minority, and having lower education, a diagnosis of cancer or lung disease, and an expected death were associated with completing an AD within the three months before death, while having the lowest quartile of assets and memory problems were inversely associated with AD completion. Minorities, those with lower education, expected death, and timing of AD completion were associated with electing aggressive care.Conclusion: Early documentation of care wishes may not be associated with an increased likelihood of electing aggressive care; however, ADs completed in the last months of life have higher rates of election of aggressive care. [ABSTRACT FROM AUTHOR]

Although advance care planning ( ACP) is associated with better care at the end of life, better quality of death, and less psychological distress in survivors, ethnic disparities in ACP completion rates have been documented and may be attributable to lack of knowledge about ACP or differences in cultural values and preferences. Despite rapid increases in the size of the Asian-American population, little is known about ACP preferences of Chinese Americans. The purpose of this study is to explore the knowledge, attitudes, and preferences of older Chinese Americans toward ACP. Focus groups with Chinese older adults (n = 34) were conducted in Mandarin, Cantonese, and English, and transcripts were analyzed using a grounded theory approach. Identified themes included knowledge and experience with ACP and end-of-life care options, health as a factor in timing of ACP and communication, and communication of end-of-life care preferences. Knowledge of and experience with ACP and end-of-life decision-making varied according to focus group, although few participants had an advance directive. Findings suggest that Chinese older adults prefer to use indirect communication strategies, such as commenting on the circumstances of others rather than directly stating their wishes, and informal contexts, such as during a family dinner rather than formal meeting, to convey their care preferences to loved ones and may employ similar tactics when communicating with clinicians. This is particularly important given the recent decision by the Centers for Medicare and Medicaid Services to provide reimbursement to physicians for engaging in advance care planning conversations. [ABSTRACT FROM AUTHOR]

Purpose of the Study: Previous studies examining preferences documented in Physician Orders for Life Sustaining Treatment (POLST) have found that most sampled POLSTs show a preference to limit care. These studies were conducted in states that are relatively ethnically homogeneous. This study investigated the POLST preferences of nursing home residents in an ethnically diverse state--California--that requires nursing homes to document whether residents execute POLST. Design and Methods: Data were collected from POLST forms executed by 941 residents in a convenience sample of 13 nursing homes in Southern California. The study analyzed data from 4 POLST form items: signatory (resident vs. surrogate decision-maker) and care preferences related to: (a) resuscitation; (b) medical intervention; and (c) artificially administered nutrition. Descriptive, comparative, and regression analyses are reported at both individual and facility levels. Results: Of reviewed POLSTs, 46.8% documented a preference for "do not resuscitate" (DNR); 47.3% documented limits on medical intervention; and 52% documented limits on artificially administered nutrition. Residents in nursing homes serving comparatively larger populations of older residents and White residents had lower odds of electing the full care option for each of the POLST's 3 care items; those in nursing homes serving comparatively larger populations of Hispanic residents had higher odds of electing long-term artificially administered nutrition. Implications: This study found lower rates of POLST choices limiting care than previous studies, possibly because the sampled nursing homes served a more ethnically- and age-diverse population. California's requirement that nursing homes document whether residents execute POLST also may have indirectly influenced choice patterns. [ABSTRACT FROM AUTHOR]

Background: A primary barrier to physician disclosure of terminal prognosis is concern that patients will lose hope. Inpatient palliative care (IPC) teams are especially posed to mediate this barrier, but little is known about patient perceptions and experience of IPC. Objective: This study aimed to elicit seriously ill patients' perspective and experience of an IPC consultation, and to explore patient attitudes toward information derived from the consultation. Methods: An exploratory, qualitative study was conducted at a large nonprofit community hospital in the Los Angeles area. An established IPC team conducted individualized consults with patients and families within 24 hours of referral. Eligible participants were English-speaking adults, aged 18 or over, who had received an IPC consultation within the previous week during their hospitalization. Purposive recruitment of patients was conducted by the IPC social worker. Interviews were conducted at bedside using a semistructured interview protocol employing open-ended questions. Results: Twelve seriously ill patients were interviewed. Four themes were identified from the interview transcripts: (1) holistic care approach, (2) knowledge/information gained, (3) hope and enlightenment, and (4) patient readiness. Conclusions: Results suggest that disclosure of a terminal prognosis does not mean loss of patient hope. Instead, hope was redefined on a goal other than cure. Presenting patients with information and increasing their knowledge about care options and resources may facilitate patients in identifying meaningful goals that are better aligned with their prognosis. [ABSTRACT FROM AUTHOR]

Little is known about the experiences of health professionals in reporting suspected elder abuse and neglect (EAN) or the perceptions of Adult Protective Services (APS) in responding to reports. The purpose of this article is to examine the attitudes and perceptions of health professionals in responding to elder mistreatment and to compare these attitudes and perceptions to those of APS workers who investigate abuse. Focus groups were conducted with APS workers (n = 9) and two types of health professionals: geriatric care managers (n = 4) and hospice staff (n = 13). Transcripts were coded inductively, and emergent themes were compared across groups using thematic analysis. Health professionals and APS workers acknowledged similar challenges resolving cases of EAN—particularly victim refusal of services or denial of abuse, limited APS authority, and large caseloads. APS workers identified unnecessary referrals and poor communication among providers as barriers to effectiveness. Health care workers noted they sometimes ignored mandatory reporting requirements, preferring to work directly with patients and families to remedy abuse. Results suggest that mandatory reporting may be a necessary but insufficient approach. Cross-agency collaboration between APS and health professionals may help enhance communications, clarify expectations, and potentially improve outcomes. Person-centered responses that link victims with community based services should also be explored to improve victim cooperation and to increase confidence in the adult protection system. [ABSTRACT FROM AUTHOR]

Objectives To determine the perspectives of seriously ill individuals on reasons for 30-day hospital readmission. Design A prospective qualitative study was conducted employing individual interviews conducted at bedside. Setting Department of Veterans Affairs Greater Los Angeles Healthcare System. Participants Seriously ill individuals with heart failure or cancer receiving inpatient palliative care and readmitted to the hospital within 30 days of hospital discharge were recruited to participate. Nine were interviewed. Measurements A semistructured interview protocol was used to elicit participant perspectives on readmission causes. Results All participants were male and had a mean age of 70.1 ± 9.5. Participants were ethnically diverse (three African Americans, three Caucasians, three Hispanic or mixed ethnic background). Six lived alone, and four did not have caregiver support. Qualitative analysis of transcripts revealed three themes relating to reasons for hospital readmission: lack of caregiver support and motivation to provide self-care, acceptance of condition and desire for aggressive care, and access to care and poor quality of care. Conclusion Participants identified potentially avoidable reasons for hospital readmission as well as causes that require rethinking regarding how community support is targeted and delivered. Participant preference for aggressive care, inability to provide self-care, and lack of caregiver support suggest the need for new and innovative mechanisms to support seriously ill community-dwelling individuals. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the impact of inpatient palliative care consultations on family members' understanding of the patient's condition, knowledge of available care options and decision-making ability. It cites family members' involvement in end-of-life decision making. Themes which emerged from the study include perceived quality of the inpatient palliative care consultation, family readiness, effect on decision making and focus on comfort and quality of life.

Little is known about characteristics of those who transition to the community after long stays in nursing facilities. Yet this information is highly relevant to efforts to reduce preventable nursing facility use. This study identifies and compares community transition among short-stay (1–90 days) and long-stay residents (91–365 days) aged 65 + using Kaplan-Meier survival estimates and logistic regression to analyze 3,762 episodes of care in Southern California. Over 90% of community discharges occurred in the first 90 days, and few characteristics predicted discharge after 90 days. The findings inform transition programs' efforts to identify and effectively target residents after 90-day stays. [ABSTRACT FROM PUBLISHER]

Background: Inpatient palliative consultation are generally provided to seriously ill hospitalized patients with the intent to alleviate pain and suffering and develop a plan of care for the patient. Although numerous benefits of this service have been documented, little is known about hospital readmission rates and factors associated with these readmissions. Objective: Our aim was to investigate factors associated with 30-day hospital readmission among patients receiving a consultation from an inpatient palliative care (ICP) team. Design: We conducted a retrospective cohort study. Setting/Subjects: Data from 408 managed care patients 65 years old and older were collected in 2007-2009 following an IPC consultation and subsequent hospital discharge. Measurements: IPC and medical service use records were utilized. Results: Among IPC patients, 10% of those discharged from the hospital were readmitted within 30 days. Factors associated with hospital readmission included being discharged from the hospital with no care in the home or to a nursing facility. Receipt of hospice or home-based palliative care post-discharge was associated with significantly lower odds of hospital readmission. Conclusions: This study found that receipt of palliative care following hospital discharge was an important factor in reducing 30-day hospital readmissions. Further study is needed to evaluate the effectiveness of longitudinal palliative care models in reducing 30-day hospital readmissions among seriously ill patients. [ABSTRACT FROM AUTHOR]

The article presents an abstract of the article "From Hospital to Home: A Brief Nurse Practitioner Intervention for Vulnerable Older Adults" by Susan Enguidanos, Nancy Gibbs and Paula Jamison.

Objectives: To test a brochure comprising hospice patient role model stories aimed at improving attitudes and knowledge of hospice among older African Americans. Design: Pre-post community-based study. Setting: Community-based organizations including senior centers, community exercise programs, churches, and senior care management services in greater Los Angeles area. Participants: Seventy-one African Americans aged 65 and older. Intervention: Hospice brochure containing theoretically driven role model stories portraying African Americans' experience with hospice, their initial attitudes and beliefs about hospice, factors influencing their enrollment in the program, and outcomes following enrollment. Measurements: Change from baseline in attitudes toward, knowledge of, and intentions to enroll in hospice. Results: Mean knowledge scores (range, 0-9) increased from 5.76 (standard deviation [SD] = 2.12) at pretest to 6.95 (SD = 1.90) at posttest ( t = −6.14, p < 0.001). Average attitude toward hospice (range, 12-72) improved 12.5% from 41.16 (SD = 5.20) to 46.29 (SD = 5.45) ( t = −7.52, p < 0.001). Intentions to enroll a family member in hospice increased from 84.5% to 92.9% ( p = 0.002) and intentions to seek hospice care for themselves increased from 83.1% to 95.8% ( p < 0.001). Conclusion: This small pre-post pilot study found that exposure to a hospice brochure containing theoretically driven, culturally parallel, role model stories was effective in improving knowledge of and attitudes toward hospice as well as intentions to enroll a family member or self in hospice care. Further study is needed to determine the impact of using this brochure within a clinical setting. [ABSTRACT FROM AUTHOR]