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Background: Hospice and palliative medicine (HPM) is a board-certified subspecialty within emergency medicine (EM), but prior studies have shown that EM residents do not receive sufficient training in HPM. Experts in HPM-EM created a consensus list of competencies for HPM training in EM residency. We evaluated how the HPM competencies integrate within the American Board of Emergency Medicine Milestones, which include the Model of the Clinical Practice of Emergency Medicine (EM Model) and the knowledge, skills, and abilities (KSA) list.Methods: Three emergency physicians independently mapped the HPM-EM competencies onto the 2019 EM Model items and the 2021 KSAs. Discrepancies were resolved by a fourth independent reviewer, and the final mapping was reviewed by all team members.Results: The EM Model included 78% (18/23) of the HPM competencies as a direct match, and we identified recommended areas for incorporating the other five. The KSAs included 43% (10/23). Most HPM competencies included in the KSAs mapped onto at least one level B (minimal necessary for competency) KSA. Three HPM competencies were not clearly included in the EM Model or in the KSAs (treating end-of-life symptoms, caring for the imminently dying, and caring for patients under hospice care).Conclusion: The majority of HPM-EM competencies are included in the current EM Model and KSAs and correspond to knowledge needed to be competent in EM. Programs relying on the EM Milestones to plan their curriculums may miss training in symptom management and care for patients at the end of life or who are on hospice.

Background: Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula.Methods: Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members.Results: The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A).Conclusion: All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.

In 2017, the Society of Critical Care Medicine released guidelines describing support for families of critically ill patients (Davidson et al., 2017). Per the guidelines, family centered critical care recognizes [...], Introduction: Improving family centered care in the PICU requires understanding the milestones that families need assistance preparing for as well as factors that facilitate or obstruct preparedness. We present a model of family preparedness for transitions in the PICU based on semistructured interviews with clinicians and families that is designed to improve family centered care through the reduction of failed or traumatic transitions. Method: We conducted semistructured interviews with 20 clinicians and 25 families in an academic PICU. Transcript analysis focused on identifying factors facilitating or obstructing family preparedness for care transitions. We analyzed interview transcripts for emergent themes and metathemes using grounded theory methodology. Results: Family preparedness for care transitions is dependent upon both cognitive and emotional preparedness. Six metathemes form a novel model for understanding the factors influencing both components of preparedness and their interrelationship. Specifically, family preparedness is influenced by (a) individualized backgrounds, coping skills, and support systems as well as the (b) emotional context, (c) care environment, (d) course of care, (e) content of preparatory information, and (f) manner in which care is coordinated to effectively deliver information. We also describe 10 transitional categories that provide context for application of the model. Discussion: Cognitive and emotional preparedness for care transitions in the PICU develops through attentiveness to six features. The conceptual model presented here will allow clinicians to support family centered care through interventions to facilitate a shared development of expectations for the future and reduce the risk of failed or traumatic transitions. Keywords: pediatric intensive care units, transitional care, patient-family relations, communication, grounded theory Supplemental materials: http://dx.doi.org/10.1037/fsh0000431.supp

Management of cancer-associated pain warrants consideration of many factors, including characterization and etiology of the pain, socioeconomic factors, medication tolerance, and substance use history. Kratom (Mitragyna speciosa) is an herbal substance with stimulant and analgesic properties that is becoming a popular drug in the United States. In this report, we present a patient with a history of opioid use disorder (OUD) who had been using high doses of kratom to alleviate progressive chest pain and dyspnea secondary to newly diagnosed stage IV lung adenocarcinoma. He underwent kratom withdrawal shortly after his index admission and was reluctant to continue full opioid agonists given his history of OUD and complex living situation. His kratom withdrawal and cancer-associated symptoms were successfully managed with buprenorphine–naloxone. Providers should obtain a careful history of novel substance use such as kratom. Furthermore, buprenorphine–naloxone is a safe and effective option to simultaneously manage kratom withdrawal and cancer-associated pain. [ABSTRACT FROM AUTHOR]

1. Upon completion of this session, participants will be able to describe the ethical challenges in decision-making for patients with life-threatening though potentially survivable injury after attempted suicide. 2. Upon completion of this session, participants will be able to analyze methods for resolving clinical and ethical conflicts related to end-of-life decision making for patients with serious mental illness. Medical decision-making for patients without decision-making capacity who have attempted suicide can present ethical challenges, particularly when a patient has a life-threatening though potentially survivable injury. We present a modified case that highlights the need for interdisciplinary guidelines and best-practices for the care of these patients. Mr. C is a 56-year-old man with history of schizoaffective disorder complicated by previous suicide attempts. He presented to the hospital following a self-inflicted gunshot wound to the head. He was intubated in the field and was found to have significant intracranial bleeding and facial disfigurement. By legal default, his younger brother was his surrogate decision-maker. After emergency stabilization, providers shared that Mr. C had an estimated 50% chance of survival if he were to proceed with a high-risk series of intracranial evacuation and reconstructive plastics procedures, followed by months of high-intensity rehabilitation. Comfort-focused care and compassionate extubation were proposed as the alternative treatment plan. The palliative care, ethics, legal, and psychiatry teams were consulted, with trauma surgery and neurosurgery co-managing. Mr. C's brother desired to transition to comfort-focused care based on his mental health history and prior conversations about goals/values. However, the psychiatry team felt a "legal and ethical obligation" existed to proceed with full treatment given the potential for survival. They felt Mr. C's diagnosis of schizoaffective disorder was not treatment refractory and raised concerns that caregiver burnout may be affecting the brother's decision-making. The surgical teams also supported proceeding with treatment. After further discussion, the hospital legal and ethics teams deemed that Mr. C's brother was acting as an appropriate surrogate. As such, Mr. C was transferred to inpatient hospice, compassionately extubated, and died with his brother at his side. Mr. C's case highlights the challenges of medical decision-making for patients with suicide attempts and life-threatening though potentially survivable injuries. These cases can lead to significant moral distress for medical providers and families. We propose a standard of care that balances surrogate decision-maker experience and knowledge of prior goals of care as well as quality of life considerations with available treatment and prognostic information. Ethical / Legal Aspects of Care; Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]