The specialty of palliative care has experienced remarkable acceptance over the last decade, with teams present in 85% of medium/large hospitals in the US. For many serious illnesses like cancer, ...advanced heart disease, stroke, and chronic obstructive pulmonary disease, routine integration of palliative care is considered standard of care. Here, Kamal et al sought to characterize the self-described future plans of the palliative care workforce and match those plans to predicted future populations eligible for palliative care.
Abstract Context Many clinical disciplines report high rates of burnout, which lead to low quality of care. Palliative care clinicians routinely manage patients with significant suffering, aiming to ...improve quality of life. As a major role of palliative care clinicians involves educating patients and caregivers regarding identifying priorities and balancing stress, we wondered how clinician self-management of burnout matches against the emotionally exhaustive nature of the work. Objectives We sought to understand the prevalence and predictors of burnout using a discipline-wide survey. Methods We asked American Academy of Hospice and Palliative Medicine clinician members to complete an electronic survey querying demographic factors, job responsibilities, and the Maslach Burnout Inventory. We performed univariate and multivariate regression analyses to identify predictors of high rates of burnout. Results We received 1357 responses (response rate 30%). Overall, we observed a burnout rate of 62%, with higher rates reported by nonphysician clinicians. Most burnout stemmed from emotional exhaustion, with depersonalization comprising a minor portion. Factors associated with higher rates of burnout include working in smaller organizations, working longer hours, being younger than 50 years, and working weekends. We did not observe different rates between palliative care clinicians and hospice clinicians. Higher rated self-management activities to mitigate burnout include participating in interpersonal relationships and taking vacations. Conclusions Burnout is a major issue facing the palliative care clinician workforce. Strategies at the discipline-wide and individual levels are needed to sustain the delivery of responsive, available, high-quality palliative care for all patients with serious illness.
Abstract Background Beliefs around deactivation of a left ventricular assist device (LVAD) vary substantially between clinicians, institutions, and patients. Therefore, we sought to understand ...perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians. Methods and Results We administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed methods design was used. From October–November 2011, 7,168 individuals were sent the survey and 440 responded. Three domains emerged: 1) LVAD as a life-sustaining therapy; 2) complexities of the process of LVAD deactivation and 3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology=92%; HPM=81%; p=0.15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology versus 2% of HPM clinicians believed a patient should be imminently dying in order to deactivate an LVAD (p=<0.001). Additionally, 87% of cardiology versus 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (p=<0.001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide. Conclusion Cardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialogue among these two specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.
Abstract Clinician burnout reduces the capacity for providers and health systems to deliver timely, high quality, patient-centered care and increases the risk that clinicians will leave practice. ...This is especially problematic in hospice and palliative care: patients are often frail, elderly, vulnerable and complex; access to care is often outstripped by need; and demand for clinical experts will increase as palliative care further integrates into usual care. Efforts to mitigate and prevent burnout currently focus on individual clinicians. However, analysis of the problem of burnout should be expanded to include both individual- and systems-level factors as well as solutions; comprehensive interventions must address both. As a society, we hold organizations responsible for acting ethically, especially when it relates to deployment and protection of valuable and constrained resources. We should similarly hold organizations responsible for being ethical stewards of the resource of highly trained and talented clinicians through comprehensive programs to address burnout.
Abstract The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. ...Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning.
Abstract Context While left ventricular assist devices as destination therapy (DT-LVAD) can improve survival, quality of life, and functional capacity in well-selected patients with advanced heart ...failure, there remain unique challenges to providing quality end-of-life care in this population. Palliative care involvement is universally recommended, but how to best operationalize this care and measure success is unknown. Objectives To characterize the process of preparedness planning (PP) for patients receiving DT-LVAD at our institution and better understand opportunities for quality improvement or procedural transferability. Methods Retrospective review of 107 consecutive patients undergoing DT-LVAD implantation at a single institution between 2009 and 2013. Information regarding demographics, advance care planning, and mortality was abstracted from the medical record and analyzed. Findings were compared with a historical cohort who received DT-LVAD implantation at the same institution prior to the development of PP (2003-2009). Results Mean age of patients receiving DT-LVAD was 64.3 years (SD±10.7). At last follow-up, 46 patients (43%) had died. Mean post-DT-LVAD survival in this group was 1.1 years (SD±1.2). 89% of patient had palliative care consultation prior to implantation, and 70% completed PP. While 66% of patients completed an advance directive (AD) preimplantation, only 2 ADs (2.8%) specifically mentioned DT-LVAD and none addressed core elements of PP. AD completion rates improved from 47% prior to our policy on PP (P=0.012). Conclusions A disconnect was evident between the rigor of PP discussions and the content of ADs in the medical record. We urge that future efforts focus on narrowing this gap.
Abstract Context Palliative care services are growing at an unprecedented pace. Yet, the characteristics of the clinician population who deliver these services are not known. Information on the ...roles, motivations, and future plans of the clinician workforce would allow for planning to sustain and grow the field. Objectives To better understand the characteristics of clinicians within the field of hospice and palliative care. Methods From June through December 2013, we conducted an electronic survey of American Academy of Hospice and Palliative Medicine members. We queried information on demographics, professional roles and responsibilities, motivations for entering the field, and future plans. We compared palliative care and hospice populations alongside clinician roles using chi-square analyses. Multivariable logistic regression was used to identify predictors of leaving the field early. Results A total of 1365 persons, representing a 30% response rate, participated. Our survey findings revealed a current palliative care clinician workforce that is older, predominantly female, and generally with less than 10 years clinical experience in the field. Most clinicians have both clinical hospice and palliative care responsibilities. Many cite personal or professional growth or influential experiences during training or practice as motivations to enter the field. Conclusion Palliative care clinicians are a heterogeneous group. We identified motivations for entering the field that can be leveraged to sustain and grow the workforce.
Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with ...chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.
PDF
