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Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

Aims: Palliative care integration improves quality of life among patients with lung cancer and their families. Despite these benefits, significant barriers persist and patients do not receive timely integration. This study sought to identify facilitators of and barriers to integration in lung cancer care. Materials & methods: Semistructured qualitative interviews were conducted with palliative care and lung cancer clinicians and analyzed using traditional content analysis. 23 clinicians were interviewed from geographically dispersed hospitals within a national healthcare system. Results: Palliative care integration improved over time, enhanced by several facilitators stratified at four levels (patient/clinician/hospital/organization). Most important among these was multidisciplinary care delivered in outpatient settings, fostering trust and relationships among clinicians which were pivotal to successful integration. Workforce shortages and limited use of primary palliative care among lung cancer clinicians need to be addressed for continued growth in the field. Conclusion: Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.

Hospitals faced unprecedented scarcity of resources without parallel in modern times during the COVID-19 pandemic. This scarcity led healthcare systems and states to develop or modify scarce resource allocation guidelines that could be implemented during "crisis standards of care" (CSC). CSC describes a significant change in healthcare operations and the level of care provided during a public health emergency.Our study provides a comprehensive examination of the latest CSC guidelines in the western region of the USA, where Alaska and Idaho declared CSC, focusing on ethical issues and health disparities.Mixed-methods survey study of physicians and/or ethicists and review of healthcare system and state allocation guidelines.Ten physicians and/or ethicists who participated in scarce resource allocation guideline development from seven healthcare systems or three state-appointed committees from the western region of the USA including Alaska, California, Idaho, Oregon, and California.All sites surveyed developed allocation guidelines, but only four (40%) were operationalized either statewide or for specific scarce resources. Most guidelines included comorbidities (70%), and half included adjustments for socioeconomic disadvantage (50%), while only one included specific priority groups (10%). Allocation tiebreakers included the life cycle principle and random number generators. Six guidelines evolved over time, removing restrictions such as age, severity of illness, and comorbidities. Additional palliative care (20%) and ethics (50%) resources were planned by some guidelines.Allocation guidelines are essential to support clinicians during public health emergencies; however, significant deficits and differences in guidelines were identified that may perpetuate structural inequities and racism. While a universal triage protocol that is equally accepted by all communities is unlikely, the lack of regional agreement on standards with justification and transparency has the potential to erode public trust and perpetuate inequity.

Context Palliative care (PC) is associated with improved quality of life, survival, and decreased healthcare use at the end of life among lung cancer patients. However, the specific elements of palliative care that may contribute to these benefits are unclear. Objectives To evaluate the associations of PC and its setting of delivery with prescriptions of symptom management medications, advance care planning (ACP), hospice enrollment, and home health care (HHC) receipt. Methods Retrospective, cohort study of patients with advanced stage (IIIB/IV) lung cancer in the Veterans Health Administration (VA) diagnosed from 2007-2013; with follow-up through 2017. Propensity score methods were used with inverse probability of treatment weighting and logistic regression modeling, adjusting for patient and tumor characteristics. Results Among 23 142 patients, 57% received PC. Compared to non-receipt of PC, PC in any setting (inpatient or outpatient) was associated with increased prescriptions of pain medications (Adjusted Odds Ratio (aOR) = 1.63, 95% CI: 1.45-1.83), constipation regimen with pain medications (aOR = 2.04, 95% CI: 1.63-2.54), and antidepressants (aOR = 1.78, 95% CI: 1.52-2.09). PC was also associated with increased ACP (aOR = 1.52, 95% CI: 1.37-1.67) and hospice enrollment (aOR = 1.39, 95% CI:1.31-1.47), and decreased HHC (aOR = 0.79, 95% CI: 0.70-.90) compared to non-receipt of PC. Receipt of PC in outpatient settings was associated with increased prescriptions of pain medications (aOR = 2.54, 95% CI: 2.13-3.04) and antidepressants (aOR = 1.76, 95% CI: 1.46-2.12), and hospice enrollment (aOR = 2.09, 95% CI: 1.90-2.31) compared to receipt of PC in inpatient settings. Conclusions PC is associated with increased use of symptom management medications, ACP, and hospice enrollment, especially when delivered in outpatient settings. These elements of care elucidate potential mechanisms for improved outcomes associated with PC and provide a framework for a primary palliative care approach among non-palliative care clinicians.

INTRODUCTION: Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain. We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs TM and the influence of hospital MA concentration. METHODS: Retrospective cohort of hospitalized Medicare patients from 2016-17 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used. RESULTS: Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95%CI:83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11,95%CI: 1.04-1.18), 30-(AOR=1.09,95%CI:1.05-1.12) and 365-day mortality (AOR=1.12,95%CI:1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level. CONCLUSIONS: MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

Background The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally. Research Questions Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists? Study Design and Methods Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system. Results Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians’ anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff. Interpretation We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

BACKGROUND: Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS: We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy

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 Copyright 2022 by the American Thoracic Society

Background Asian Americans are the fastest-growing ethnic minority in the USA, but we know little about the end-of-life care for this population. Objective Compare invasive mechanical ventilation (IMV) use between older Asian and White decedents with hospitalization in the last 30 days of life. Design Population-based retrospective cohort study. Participants A 20% random sample of 2000–2017 Medicare fee-for-service decedents who were 66 years or older and had a hospitalization in the last 30 days of life. Exposure White and Asian ethnicity as collected by the Social Security Administration. Main Measures We identified IMV using validated procedural codes. We compared IMV use between Asian and White fee-for-service decedents using random-effects logistic regression analysis, adjusting for sociodemographics, admitting diagnosis, comorbidities, and secular trends. Key Results From 2000 to 2017, we identified 2.1 million White (54.5% female, 82.4±8.1 mean age) and 28,328 Asian (50.8% female, 82.6±8.1 mean age) Medicare fee-for-service decedents hospitalized in the last 30 days. Compared to White decedents, Asian fee-for-service decedents have an increased adjusted odds ratio (AOR) of 1.42 (95%CI: 1.38–1.47) for IMV. In sub-analyses, Asians’ AOR for IMV differed by admitting diagnoses (cancer AOR=1.32, 95%CI: 1.15–1.51; congestive heart failure AOR=1.75, 95%CI: 1.47–2.08; dementia AOR=1.93, 95%CI: 1.70–2.20; and chronic obstructive pulmonary disease AOR=2.25, 95%CI: 1.76–2.89). Conclusions Compared to White decedents, Asian Medicare decedents are more likely to receive IMV when hospitalized at the end-of-life, especially among patients with non-cancer admitting diagnoses. Future research to better understand the reasons for these differences and perceived quality of end-of-life care among Asian Americans is urgently needed.

Background Palliative care is associated with improved survival and quality of life among patients with lung cancer; however, its influence on health-care utilization and quality of care is unclear. Research Question Is palliative care, and the setting in which it occurs, associated with health-care resource utilization and quality of care among patients with advanced lung cancer? Study Design and Methods This was a retrospective cohort study of 23,142 patients with stage IIIB/IV lung cancer in the Veterans Affairs HealthCare System between 2007 and 2013. Exposures included the receipt of specialist-delivered palliative care, and the setting of the initial palliative care encounter (inpatient or outpatient) received after cancer diagnosis. Primary outcomes included rates of ED visits, along with rates of hospitalization and odds of ICU admission within the last 30 days of life. Secondary outcomes included any health-care utilization (ED, hospital, or ICU) related to chemotherapy toxicity. We used propensity score methods to perform Poisson and logistic regression modeling. Results Among the 23,142 patients, 57% received palliative care, and 36% of initial palliative care encounters were outpatient. Compared with no palliative care, initial palliative care encounter in the outpatient setting was associated with reduced rates of ED visits (adjusted incidence rate ratio [aIRR], 0.86; 95% CI, 0.77-0.96) and hospitalizations in the last 30 days of life (aIRR, 0.64; 95% CI, 0.59-0.70). Initial palliative care encounters in both inpatient (adjusted OR [aOR], 0.63; 95% CI, 0.53-0.75) and outpatient (aOR, 0.42; 95% CI, 0.35-0.52) settings were associated with reduced odds of ICU admission in the last 30 days of life. Palliative care was also associated with reduced health-care utilization related to chemotherapy toxicity (aOR, 0.88; 95% CI, 0.82-0.95). Interpretation Palliative care (particularly in outpatient settings) is associated with reduced health-care utilization at the end of life and may improve the quality of care among patients with advanced lung cancer. These findings support the role of palliative care as an important component of comprehensive cancer care and highlight the potential benefits of outpatient palliative care services.

Rationale: Because of improvements in screening, there is an increasing number of patients with early-stage non-small-cell lung cancer (NSCLC) who are making treatment decisions.Objectives: Among patients with suspected stage I NSCLC, we evaluated longitudinal patient-centered outcomes (PCOs) and the association of changes in PCOs with treatment modality, stereotactic body radiotherapy (SBRT) compared with surgical resection.Methods: We conducted a multisite, prospective, observational cohort study at seven medical institutions. We evaluated minimum clinically important differences of PCOs at four time points (during treatment, 4-6 wk after treatment, 6 mo after treatment, and 12 mo after treatment) compared with pretreatment values using validated instruments. We used adjusted linear mixed models to examine whether the association between treatment and European Organization for Research and Treatment of Cancer global and physical quality-of-life (QOL) scales differed over time.Results: We included 127 individuals with stage I NSCLC (53 surgery, 74 SBRT). At 12 months, approximately 30% of patients remaining in each group demonstrated a clinical deterioration on global QOL from baseline. There was a significant difference in slopes between treatment groups on global QOL (-12.86; 95% confidence interval [CI], -13.34 to -12.37) and physical QOL (-28.71; 95% CI, -29.13 to -28.29) between baseline and during treatment, with the steeper decline observed among those who underwent surgery. Differences in slopes between treatment groups were not significant at all other time points.Conclusions: Approximately 30% of patients with stage I NSCLC have a clinically significant decrease in QOL 1 year after SBRT or surgical resection. Surgical resection was associated with steeper declines in QOL immediately after treatment compared with SBRT; however, these declines were not lasting and resolved within a year for most patients. Our results may facilitate treatment option discussions for patients receiving treatment for early-stage NSCLC.

Background/objectives Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation. Design Retrospective cohort study. Setting Acute-care hospitals in the United States. Participants Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race. Measurement Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV. Results Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51). Conclusion IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

BACKGROUND: Predicting death in a cohort of clinically diverse, multi-condition hospitalized patients is difficult. This frequently hinders timely serious illness care conversations. Prognostic models that can determine 6-month death risk at the time of hospital admission can improve access to serious illness care conversations. OBJECTIVE: The objective is to determine if the demographic, vital sign, and laboratory data from the first 48 h of a hospitalization can be used to accurately quantify 6-month mortality risk. DESIGN: This is a retrospective study using electronic medical record data linked with the state death registry. PARTICIPANTS: Participants were 158,323 hospitalized patients within a 6-hospital network over a 6-year period. MAIN MEASURES: Main measures are the following: the first set of vital signs, complete blood count, basic and complete metabolic panel, serum lactate, pro-BNP, troponin-I, INR, aPTT, demographic information, and associated ICD codes. The outcome of interest was death within 6 months. KEY RESULTS: Model performance was measured on the validation dataset. A random forest model—mini serious illness algorithm—used 8 variables from the initial 48 h of hospitalization and predicted death within 6 months with an AUC of 0.92 (0.91–0.93). Red cell distribution width was the most important prognostic variable. min-SIA (mini serious illness algorithm) was very well calibrated and estimated the probability of death to within 10% of the actual value. The discriminative ability of the min-SIA was significantly better than historical estimates of clinician performance. CONCLUSION: min-SIA algorithm can identify patients at high risk of 6-month mortality at the time of hospital admission. It can be used to improved access to timely, serious illness care conversations in high-risk patients. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05733-1) contains supplementary material, which is available to authorized users.

Background Lung cancer survivors are at risk of accelerated declines in physical functioning attributed to cancer treatment. However, it is unknown whether patients experience the same rate of functional decline and how symptoms may contribute to different trajectories. Objectives The aims of this study were to identify interindividual differences in the pattern and rate of change in self-reported functioning in lung cancer survivors and examine whether and how symptoms are related to physical functioning over time. Methods This was a secondary data analysis in 72 lung cancer survivors. Multilevel modeling was used to estimate trajectories of self-reported physical functioning over 1 year and assess the relation between functioning, fatigue, depressive symptoms, and pain severity across time. Results Within the sample, average physical functioning did not significantly decrease (coefficient, -0.46; 95% confidence interval [CI] = -2.85 to 0.94) over time. However, among individual lung cancer survivors, baseline physical functioning varied significantly (SD, 20.76; 95% CI, 16.84-25.59) and changed at significantly different rates over 1 year (SD, 3.50; 95% CI, 2.13-5.68). Fatigue, assessed over 1 year, was the only significant symptom predictor of physical functioning changes over time (coefficient = 1.03; 95% CI, 0.79-1.27). Conclusions In this sample of lung cancer survivors, not all survivors experienced the same rate of self-reported functional decline and those with lower levels of fatigue reported better physical functioning. Implications for practice Nurses should recognize that some lung cancer survivors may have faster rates of functional declines than others, which may be related to fatigue severity. Early identification and management of fatigue could help avoid or delay future disability.

Study objective Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). Methods This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. Results A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). Conclusion Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients’ preferences.

The COVID-19 pandemic has strained health care systems and has resulted in widespread critical care staffing shortages, negatively impacting the quality of care delivered.How have hospitals' emergency responses to the pandemic influenced the well-being of frontline intensivists, and do any potential strategies exist to improve their well-being and to help preserve the critical care workforce?We conducted semistructured interviews of intensivists at clusters of tertiary and community hospitals located in six regions across the United States between August and November 2020 using the "four S" framework of acute surge planning (ie, space, staff, stuff, and system) to organize the interview guide. We then used inductive thematic analysis to identify themes describing the influence of hospitals' emergency responses on intensivists' well-being.Thirty-three intensivists from seven tertiary and six community hospitals participated. Intensivists reported experiencing substantial moral distress, particularly because of restricted visitor policies and their perceived negative impacts on patients, families, and staff. Intensivists also frequently reported burnout symptoms as a result of their experiences with patient death, exhaustion over the pandemic's duration, and perceived lack of support from colleagues and hospitals. We identified several potentially modifiable factors perceived to improve morale, including the proactive provision of mental health resources, establishment of formal backup schedules for physicians, and clear actions demonstrating that clinicians are valued by their institutions.Restrictive visitation policies contributed to moral distress as reported by intensivists, highlighting the need to reconsider the risks and benefits of these policies. We also identified several interventions as perceived by intensivists that may help to mitigate moral distress and to improve burnout as part of efforts to preserve the critical care workforce.

Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.

Importance Head and neck cancer (HNC) survivors are about twice as likely to die by suicide compared with other cancer survivors. Objective To examine the associations between precancer mental health and pain and postcancer receipt of mental health, substance use disorder (SUD), or palliative care services with risk of suicidal self-directed violence (SSDV). Design, setting, and participants This retrospective cohort study used the Veterans Health Administration data of 7803 veterans with a diagnosis of HNC (stage I-IVB) who received cancer treatment between January 1, 2012, and January 1, 2018. Data were analyzed between May 2020 and July 2021. Exposures Presence of precancer chronic pain and SUD diagnoses, and postcancer SUD, mental health, or palliative care treatment. Exposures were defined using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in Veterans Health Administration administrative data. Main outcomes and measures Documented SSDV event, including suicide attempt or death by suicide, after HNC diagnosis. Results Among the cohort of 7803 veterans (7685 [98.4%] male; mean [SD] age, 65 [10.7] years), 72 (0.9%) had at least 1 documented SSDV event following their cancer diagnosis, and 51 (0.7%) died by suicide. Four adjusted modified Poisson regression analyses identified that precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI 1.54-4.32) or mood disorder diagnoses (IRR, 1.95; 95% CI, 1.17-3.24) were associated with higher risk of postcancer SSDV. Those who had at least 1 documented mental health (IRR, 2.73; 95% CI, 1.24-6.03) or SUD (IRR, 3.92; 95% CI, 2.46-6.24) treatment encounter in the 90 days following HNC diagnosis were at higher risk for SSDV. A palliative care encounter within 90 days of postcancer diagnosis was associated with decreased risk of SSVD (IRR, 0.49; 95% CI, 0.31-0.78). Conclusions and relevance In this cohort study, a high proportion of HNC survivors with an SSVD event died from their injuries. Identification of risk factors for SSDV among HNC survivors may help direct additional resources to those who are at high risk. Referral to palliative care appears to be an important component of supportive oncologic care to reduce the risk of SSDV.

Introduction With advances in treatments among patients with lung cancer, it is increasingly important to understand patients’ values and preferences to facilitate shared decision making. Methods Prospective, multicenter study of patients with treated stage I lung cancer. At the time of study participation, participants were 4–6 months posttreatment. Value clarification and discrete choice methods were used to elicit participants’ values and treatment preferences regarding stereotactic body radiation therapy (SBRT) and surgical resection using only treatment attributes. Results Among 114 participants, mean age was 70 years (Standard Deviation = 7.9), 65% were male, 68 (60%) received SBRT and 46 (40%) received surgery. More participants valued independence and quality of life (QOL) as “most important” compared to survival or cancer recurrence. Most participants (83%) were willing to accept lung cancer treatment with a 2% chance of periprocedural death for only one additional year of life. Participants also valued independence more than additional years of life as most (86%) were unwilling to accept either permanent placement in a nursing home or being limited to a bed/chair for four additional years of life. Surprisingly, treatment discordance was common as 49% of participants preferred the alternative lung cancer treatment than what they received. Conclusions Among participants with early stage lung cancer, maintaining independence and QOL were more highly valued than survival or cancer recurrence. Participants were willing to accept high periprocedural mortality, but not severe deficits affecting QOL when considering treatment. Treatment discordance was common among participants who received SBRT or surgery. Understanding patients’ values and preferences regarding treatment decisions is essential to foster shared decision making and ensure treatment plans are consistent with patients’ goals. Clinicians need more resources to engage in high quality communication during lung cancer treatment discussions.

Introduction Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer. Methods Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics. Results Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC. Conclusions EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished wellbeing. Despite the potential to confer significant quality of life benefits for patients and their care partners and to improve end-of-life care, specialist palliative care is rarely implemented in COPD and when initiated it often occurs only at the very end of life. Primary palliative care delivered by frontline clinicians is a feasible model, but is not routinely integrated in COPD. In this review, we discuss the following: 1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; 2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and, 3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. In the end, this review solidifies that palliative care is much more than hospice and end-of-life care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the end of life to provide comprehensive support for patients and their care partners and to better prepare them for the end of life.

The authors systematically reviewed and summarized exercise trials in persons with lung cancer on (a) attention to the principles of exercise training (specificity, progression, overload, initial values, reversibility, and diminishing returns); (b) methodological reporting of FITT (frequency, intensity, time, and type) components; and (c) reporting on participant adherence to prescribed FITT. Randomized controlled trials of exercise that reported on ≥1 physical fitness, physical function, or body composition outcome in persons with lung cancer were included. Of 20 trial arms, none incorporated all principles of exercise training. Specificity was included by 95%, progression by 45%, overload by 75%, and initial values by 80%, while one trial arm applied reversibility and diminishing returns. Fourteen interventions reported all FITT components; however, none reported adherence to each component. Including the principles of training and reporting FITT components will contribute to better understanding of the efficacy of exercise for persons with lung cancer and inform evidence-based exercise prescriptions.

Lung cancer is the leading cause of cancer-related mortality in the United States for both men and women, accounting for about one out of every four cancer deaths. Patients with lung cancer also suffer from high disease-related suffering due to considerable physical and psychological symptom burden during and after completion of cancer treatment, well into survivorship. This chapter examines the role of palliative care to improve patients’ quality of life and increase the quality of cancer care supported by a thorough review of the available evidence.

Objective Patients with lung cancer experience significant declines in psychosocial and physical function during and after treatment that impact quality of life (QOL) and survival. Yoga is a potential strategy to mitigate functional decline among patients with lung cancer. Methods A single group 12-week pilot trial of low-moderate intensity yoga among patients with stage I-IV lung cancer and their partners (n = 46; 23 patient-partner dyads) during cancer treatment from two hospital systems. Feasibility, acceptability, descriptive statistics, and Cohen d effect sizes were calculated at 6 and 12-weeks for psychosocial and physical outcomes using validated questionnaires and assessments. Results At 6 and 12-weeks, retention was 65% and withdrawals were mainly due to disease progression. Among study completers (n = 26; 13 dyads) adherence was 80%. Comparing baseline to 12-week measurements, fatigue, depression symptoms, and sleep disturbance improved in 54% of participants for all three measures (Cohen's d = 0.40-0.53). QOL improved in 77% of participants (Cohen's d = 0.34). Upper and lower body flexibility, and lower body strength improved in 92%, 85% and 77% of participants, respectively (Cohen's d = 0.39-1.08). Six-minute walk test improved in 62% of participants an average of 32 meters (SD = 11.3; Cohen's d = 0.17). No serious adverse events were reported. Conclusions Among patients with stage I-IV lung cancer including active treatment, a 12-week partner-supported yoga program is feasible, acceptable, and improved psychosocial and physical function. Low-intensity yoga may be a complimentary approach to reduce the effects of cancer treatment, however, more research is needed to determine the efficacy of partner-supported yoga to mitigate functional decline.

INTRODUCTION: The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advancer illness to document end-of-life (EOL) care preferences. We examiner the characteristics and associated EOL care among Veterans with and without a registered POLST. METHODS: Retrospective, cohort study of advancer-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examiner a subgroup of 346 Oregon residents. We obtainer clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We comparer hospice enrollment and place of death between those with and without a registered POLST. RESULTS: Twenty-two (n = 77) percent of our cohort had registered POLST forms. Comparer to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 rays vs 119 rays). Those with a registered POLST were more likely to be enroller in hospice (adjuster odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01–5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12–0.59). CONCLUSION: There was low submission to the POLST Registry among Veterans who receiver care in Veterans’ Health Administration. Veterans who had a registered POLST were more likely to be enroller in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.

Background Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear. Research Question The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes. Study Design and Methods This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL). Results Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82). Interpretation High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.

Lung cancer survivors are at risk of accelerated declines in physical functioning attributed to cancer treatment. However, it is unknown whether patients experience the same rate of functional decline and how symptoms may contribute to different trajectories.The aims of this study were to identify interindividual differences in the pattern and rate of change in self-reported functioning in lung cancer survivors and examine whether and how symptoms are related to physical functioning over time.This was a secondary data analysis in 72 lung cancer survivors. Multilevel modeling was used to estimate trajectories of self-reported physical functioning over 1 year and assess the relation between functioning, fatigue, depressive symptoms, and pain severity across time.Within the sample, average physical functioning did not significantly decrease (coefficient, -0.46; 95% confidence interval [CI] = -2.85 to 0.94) over time. However, among individual lung cancer survivors, baseline physical functioning varied significantly (SD, 20.76; 95% CI, 16.84-25.59) and changed at significantly different rates over 1 year (SD, 3.50; 95% CI, 2.13-5.68). Fatigue, assessed over 1 year, was the only significant symptom predictor of physical functioning changes over time (coefficient = 1.03; 95% CI, 0.79-1.27).In this sample of lung cancer survivors, not all survivors experienced the same rate of self-reported functional decline and those with lower levels of fatigue reported better physical functioning.Nurses should recognize that some lung cancer survivors may have faster rates of functional declines than others, which may be related to fatigue severity. Early identification and management of fatigue could help avoid or delay future disability.

Patient-centered outcomes research (PCOR) represents a paradigm shift in research methods aimed to create the body of evidence that supports clinical practice and informs health care decisions. PCOR integrates patients and other key stakeholders including family members, policy makers, clinicians, and patient advocates and advocacy groups as research partners throughout all stages of the research process. The importance of PCOR has received increased recognition, yet there is little evidence available to help guide researchers interested in the design and conduct of PCOR. In May 2014, we convened a workshop to identify key issues related to designing, conducting, and disseminating findings from PCOR studies. Workshop participants included a diverse group of patients, patient advocates, clinicians (physicians, nurses, psychologists, and advanced practice providers), researchers, administrators, and funders within and beyond the pulmonary, critical care, and sleep medicine communities. Participants identified important issues and considerations to address when undertaking PCOR. In this report, we summarize the results of this workshop to inform members of the pulmonary, sleep, and critical care community interested in participating in PCOR. Key findings include the following: 1) requirements for research to be considered PCOR; 2) the potential significant impact of PCOR on patients, clinicians, and researchers; 3) guiding principles and practical strategies to form successful patient-centered research partnerships, conduct PCOR, and disseminate study results to a broad audience of stakeholders; 4) benefits and challenges of PCOR for researchers; and 5) resources available within the American Thoracic Society to help with the conduct of PCOR.

Introduction Given the high prevalence of smoking among Veterans and the economic, social, and clinical implications, it is important to understand the factors that contribute to smoking in order to focus efforts to mitigate these factors and improve smoking cessation efforts among Veterans. The availability of research on smoking in Veterans compared with civilians is limited given the military-specific differences in their life course. We aimed to identify military-specific factors combined with sociodemographic factors for ever smoking and current smoking among Veterans to inform future interventions. Materials and methods We used data from the 2010 National Survey of Veterans, the most current, to analyze the association of sociodemographic and military-specific factors with ever versus never smoking, and current versus past smoking using multiple variable logistic regression models (IRB#4125). Results Among 8,618 respondents, the proportions of current, past, and never smokers were 17%, 48%, and 34%, respectively. Sociodemographic factors associated with ever smoking were female gender, educational attainment of less than a bachelor's degree, and being divorced/separated/widowed. Military-specific factors associated with ever smoking were exposure to dead/dying/wounded soldiers during service, and past, current, and unsure enrollment in Veterans Affairs healthcare. Never smoking was associated with Hispanic ethnicity, income over $75,000, and reporting fair or poor health. Military factors associated with never smoking were presence of a service-connected disability and military service July 1964 or earlier (i.e., pre-Vietnam). Among 5,652 ever smokers, sociodemographic factors associated with current smoking were age less than 65, being non-Hispanic black, educational attainment of less than a bachelor's degree, being divorced/separated/widowed, never married, and having no insurance. Factors associated with reduced likelihood of current smoking compared with past smoking included income >$41,000 and reporting fair or poor health. Military-specific variables associated with reduced likelihood of current smoking were service era of May 1975 or later (i.e., post-Vietnam) and 5 or more years of service. Conclusion Military-specific variables are associated with smoking behaviors among Veterans. Findings from this study that exposure to dead/dying/wounded soldiers, service era, duration of service, service-connected disability status, and enrollment in VA care all influence smoking in Veterans, can inform prevention and cessation efforts in part by encouraging alternative healthy habits or cessation techniques in subgroups of Veterans with particular military backgrounds. By assessing risk factors in this unique population future research can leverage these findings to determine mechanisms that help explain these associations. Identifying factors associated with smoking offers insights for smoking cessation and prevention interventions given the military experiences and increased smoking incidence among Veterans.

BACKGROUND Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems. METHODS This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used. RESULTS From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment. CONCLUSIONS Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2017. © 2017 American Cancer Society.

Rationale: Gender gaps exist in academic leadership positions in critical care. Peer-reviewed publications are crucial to career advancement, and yet little is known regarding gender differences in...

We have read with great interest the retrospective population-based cohort study by Sullivan et al.1 They found an association of early palliative care (received 0 to 30 days after cancer diagnosis) with decreased survival (adjusted hazard ratio, 2.13 ; 95% CI, 1.97-2.30) in patients with advanced lung cancer. The authors used the propensity score method for reduction of selection bias among groups. The propensity score included factors such as the Charlson Comorbidity Index score and the Functional Comorbidity Index score. However, these parameters do not represent the true performance status of patients. Performance status is one of the major factors in cancer treatment decision-making and is assessed using the Eastern Cooperative Oncology Group scale2 or the Karnofsky scale.3 In addition, performance status is also associated with specialists’ decisions to deliver palliative care. Therefore, patients with greater functional impairment are more likely to receive palliative care sooner.