Surf's Up! Riding the Wave of Palliative Medicine: The Latest in Caring for Patients with Serious Illness-Slides

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This presentation from SHM Converge 2024, delivered by Dr. Aziz Ansari and Dr. Kencee Graves, summarizes recent advances and practical insights in palliative medicine for hospitalists managing seriously ill patients. The speakers focus on clinically relevant, practice-changing research from 2022-2023, handpicked from 15 leading journals.<br /><br />Key domains addressed include pain and dyspnea management, non-pain symptom control, early communication, advance care planning, diversity and equity, and healthcare utilization.<br /><br />In pain and dyspnea, studies support using low-dose short-acting opioids for breathlessness in COPD and cancer, cautioning against early use of long-acting opioids or continuous infusions unless opioid tolerance is established. Opioids other than morphine, such as fentanyl or oxycodone, can be effective. Regarding refractory nausea not related to chemotherapy, low-dose olanzapine (starting at 2.5 mg nightly) shows benefit but requires monitoring for QTc prolongation.<br /><br />For delirium in ICU patients, haloperidol shows no clear mortality benefit or harm, indicating cautious use mainly for symptom relief. Delirium in critically ill cancer patients significantly increases mortality and length of stay, underscoring the need for vigilant assessment. Behavioral symptoms in dementia correlate with worse hospital outcomes, advocating for early goals-of-care discussions. Methylphenidate may improve apathy in dementia.<br /><br />Communication and goals of care discussions remain challenging but essential. Tools like the Serious Illness Risk Indicator (SIRI) help prioritize patients at high mortality risk. Interventions such as structured family meetings and programs like the 3 Wishes Project improve family support and end-of-life care.<br /><br />Advance care planning faces barriers, including patients unable to identify trusted healthcare agents, especially among vulnerable populations like those with chronic kidney disease, cirrhosis, or homelessness. Data affirm that non-cancer serious illnesses benefit from palliative care, with reductions in hospital and ED use, symptom burden, and burdensome interventions.<br /><br />Prognostic models for community-dwelling dementia patients aid clinical decision-making. Mechanical ventilation offers limited survival benefits in advanced dementia with pneumonia, highlighting importance of aligning care with patient goals.<br /><br />Finally, integrating geriatric and palliative specialists into interdisciplinary rounds can reduce hospital length of stay modestly, though implementation challenges remain.<br /><br />Overall, the presenters emphasize practical application of emerging evidence to improve symptom management, communication, equitable care, and resource utilization for seriously ill hospitalized patients.
Keywords
palliative medicine
hospitalists
pain management
dyspnea
opioids
delirium
advance care planning
communication
serious illness risk indicator
geriatric integration