palliative care for patients with hiv: challenges and controversies (509): hiv sig
TRANSCRIPT
406 Vol. 43 No. 2 February 2012Schedule With Abstracts
PVS patients present unique challenges for every-one involved in caring for them.Families andclini-cians often face difficultly in discussing goals ofcare. Clinicians are often frustrated in what theyperceive to be meaningless and futile care, whilefamilies are caught in a commitment made longago. Patients, on the other hand, may be sufferingin a ‘‘dimensionless limbo.’’ Palliative medicinespecialists have an important responsibility in car-ing for these patients and their families.This session will focus on the clinical care of PVSpatients, guidance for families and support forstaff. A series of cases will be presented to illus-trate a practical approach for re-evaluating thetreatment goals for these patients. This ap-proach requires mastering the following skills:exploring the deeper meaning of decisionsmade by families, sharing the burden of decisionmaking with the family, explaining the currentstatus and likely future clinical course, while in-corporating identified spiritual concerns. Mean-ingful goals of care discussions for PVS patientsare often neglected by the medical community,making them particularly challenging. They rep-resent an opportunity for palliative medicinespecialists to spearhead needed reform in thecare of these patients.
SIG Symposia
Supportive and Palliative OncologyLiterature: Quantity, Scope, Design,Challenges, and Opportunities (508)Research SIGDavid Hui, MD MSc FRCPC, MD Anderson Can-cer Center, Houston, TX. Masanori Mori, MD,University of Vermont College of Medicine, Bur-lington, VT. Henrique Parsons, MD, MD Ander-son Cancer Center, Houston, TX.(All authors listed above for this session have dis-closed no relevant financial relationships.)
Objectives1. Review the quantity, scope and design of the
recent supportive and palliative oncologyliterature.
2. Examine the challenges unique to supportiveand palliative oncology research.
3. Discuss strategies for improving the quantityand quality of supportive and palliative on-cology literature.
The absolute number of palliative oncologystudies has increased over time. However the
proportion of palliative oncology publicationsrelated to the greater cancer literature has actu-ally decreased. The supportive and palliative on-cology literature is extremely diverse and highlycomplex. This session aims to provide a compre-hensive overview of the quantity, scope, and de-sign of the palliative care literature baseda recent systematic review, and to identify cur-rent challenges and opportunities for growth.The field of palliative care transects numeroushealth disciplines and domains, and coversa myriad of topics ranging from symptom man-agement to psychosocial care, spiritual issues,health services, communication, decision mak-ing, ethics, education and research methodolo-gies. The study population also varies widely,including patients with various oncologic diag-noses and at different stages of illness, theircaregivers and health professionals. Commonstudy designs to address research questions inthe supportive and palliative oncology literatureinclude case reports, case series, population-based studies, cross sectional surveys, cohortstudies, randomized controlled trials and quali-tative studies. Using a framework for classifyingsupportive and palliative oncology studies sys-tematically, we will discuss various study designsused to investigate different research topics,and highlight areas of deficiency requiring fur-ther research. We will also provide an evi-dence-based review of the many challengesassociated with conducting supportive and palli-ative oncology research, including limited fund-ing, few trained personnel, difficulty inrecruiting patients, high attrition rates, limitednumber of validated outcome measures, andlack of standardized definitions. Finally, wewill discuss practical strategies to advance sup-portive and palliative oncology research. Thelast 10 minutes will be available for questionsand discussions.
Palliative Care for Patients With HIV:Challenges and Controversies (509)HIV SIGChristopher Blais, MD MPH FACP FAAHPM,Ochsner Health System, New Orleans, LA. PeterSelwyn, MD MPH, Montefiore Medical Centerand Albert Einstein College of Medicine, Bronx,NY. Rodney Tucker, MD MMM FAAHPM, UABCenter for Palliative and Supportive Care, Birming-ham, AL. Nancy Hutton, MD FAAP FAAHPM,
Vol. 43 No. 2 February 2012 407Schedule With Abstracts
Johns Hopkins University School of Medicine, Bal-timore, MD. Jessica Merlin, MD MBA, Mount SinaiSchool of Medicine, New York, NY.(All authors listed above for this session have dis-closed no relevant financial relationships withthe following exception: Hutton’s spouse isa stockholder with Merck.)
Objectives1. Update palliative care providers on the cur-
rent epidemiology of HIV morbidity andmortality.
2. Review several contemporary challenges andcontroversies in the palliative care of patientswith HIV.
The epidemiology of HIV has changed dramat-ically since the development of protease inhibi-tors and highly active antiretroviral therapy inthe mid to late 1990’s. HIV has becomea chronic disease; life expectancy for patientson antiretroviral therapy approaches that ofthe general population, and children withHIV are now living into adolescence and adult-hood. However, HIV-infected patients experi-ence increased symptom burden. The cause ofthis is unclear, but may be due to increasingco-morbidities such as cardiovascular disease,non-AIDS-defining malignancies, and hepatitisC co-infection, and the adverse effects of long-term antiretroviral therapy. In addition, pa-tients who are unable to access treatment dueto social barriers, psychiatric, or substanceabuse co-morbidities still die of their disease.The objectives of this session are to update pal-liative care providers on the current epidemiol-ogy of HIV morbidity and mortality, and toreview several contemporary challenges andcontroversies in the palliative care of patientswith HIV. To accomplish these objectives, wewill present three interactive cases. The firstcase will describe a patient dying of HIV infec-tion secondary to several years of psychosocialnon-adherence, whose providers are torn be-tween continuing to try to prescribe antiretrovi-ral therapy, referring the patient to hospice, orboth. The second case will describe the chal-lenges of managing chronic pain in an HIV-in-fected patient doing well on antiretroviraltherapy who has a history of substance abuse.The third case will describe an adolescent withHIV whose parents have died of the disease,and will explore issues of survivorship, coping,and healthcare decision-making, including ad-vanced directives.
11:15 ame12:15 pm
Concurrent Sessions
Integrating Palliative and Critical Care:Development and Evaluation of a QualityImprovement Intervention (510)Award for Excellence in Scientific Researchin Palliative CareJ. Randall Curtis, MD MPH, HarborviewMedicalCenter University of Washington, Seattle, WA.(Curtis has disclosed no relevant financialrelationships.)
Objectives1. Identify current problems with palliative and
end-of-life care in the ICU and potentialsolutions
2. Understand recent advances concerningcommunication with families in the ICUand the empirical basis for a quality improve-ment intervention designed to improve palli-ative care in the ICU
3. Review the evaluation of this interventionand the lessons for the future
Approximately one in five deaths in the U.S. oc-curs in or shortly after a stay in the ICU. TheICU is a setting where clinicians, patients (ifthey are able), and families must commonlymake decisions about the value of starting orcontinuing life-sustaining treatments whenthese treatments seem unlikely to be successful.Historically, there has been marked variabilityin approaches to decision-making about life-sus-taining treatments in the ICU: variability acrossdifferent regions, but also across different phy-sicians in the same institution. More recently,there has been increasing consensus on thevalue of some type of ‘‘shared decision-making’’in the ICU that includes sharing responsibilitybetween the patient’s family and the clinicianscaring for the patient. However, existing datasuggests most physicians do not accomplishthe basic components of shared decision-making. A number of recent studies havedeveloped an evidence base for improving com-munication with families in the ICU and im-proving decision-making about life-sustainingand about end-of-life care. This presentationwill review the development of a quality im-provement intervention that was based on thesestudies and designed to improve palliative andend-of-life care in the ICU as well as a before-after study and a cluster randomized trial