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Poster Abstracts

Pushing Palliative Care Upstream: Integrationinto a Community-Based Oncology Practice(S701)Jennifer Blechman, MD, Partners in Care, Bend, OR.

Objectives� Show one method of integrating palliative careinto an oncology practice.

� Demonstrate metrics tracked and methods used.Original Research Background. It is now well estab-lished that palliative care is an integral part of cancertreatment, recommended by the National CancerComprehensive Network for evidence-based practices.Partners in Care is a non-profit, community-based hos-pice/home health agency in Bend OR, and consistentwith national trends, it receives late oncology referralsto hospice. Partnership with a multispecialty groupwas established to allow for a palliative care specialistto be embedded into their oncology clinic.Research Objectives. The hypothesis is that pallia-tive care involvement will result in more referrals tohospice with longer length of stays, improved symp-tom burden, and enhanced completion of advancecare plans (ACPs).Methods. Palliative care consults are offered 2 daysper week in the oncology clinic. Triggers have beencreated to facilitate consultation. Quality metricshave been carefully tracked and include symptomscores, advance care planning, and transition andlength of stay for hospice referrals. Financial supporthas been provided through grant funding from localinsurance and community foundations.Results. Over 10 months, 116 new oncology patientswere seen, and they had an average 1.9 visits. Docu-mented ACP discussions occurred in 85% patients.Of patients with moderate to severe pain and dyspnea,scores improved by 65% and 50% respectively. Lengthof stay in hospice increased from 26 to 36 days. All ofthe patient respondents surveyed would recommendour service to others. Provider respondents 100%strongly agree that objectives were met when they re-quested a palliative care consult.Conclusion. Palliative care has been successfullyintegrated into a community-based oncology practice,resulting in increased access to palliative care,increased utilization of and length of stay in hospice,improved symptom management, increased use ofACP, and enhanced patient/family satisfaction.Implications for Research, Policy orPractice. Future directions include using Quality

Data Collection Tool (QDACT) to better track qualitymeasures, inclusion of a social worker, and alignmentwith insurers and ACOs for cost support and data an-alytics.

We’re the Eyes and the Ears, but We Don’t Have aVoice: Perspectives of Hospice Aides (S702)Djin Lai, BSN, RN, University of Utah, Salt Lake City,UT. Katherine Doyon, BSN MS, University of Utah,Salt Lake City, UT. Kristin Cloyes, RN PhD, Universityof Utah, Salt Lake City, UT. Lee Ellington, PhD, Uni-versity of Utah, Salt Lake City, UT. Margaret Clayton,APRN PhD, University of Utah, Salt Lake City, UT.

Objectives� Articulate at least two issues that affect percep-tions of marginalization among hospice aides.

� Describe at least two implications of hospiceaides’ marginalization within the hospice team.

Original Research Background. Interdisciplinaryteams have been shown to improve symptom manage-ment and reduce hospitalizations in home healthcare.The Institute of Medicine identifies communicationand collaboration within the hospice interdisciplinaryteam (IDT) as a priority, yet despite spending the ma-jority of time with patients and caregivers, hospiceaides’ perceptions of team-based patient care isunknown.

Research Objectives. This study seeks to examinehow hospice aides perceive their roles in the IDTand their contributions to patient-centered, end-of-life care.

Methods. This qualitative descriptive study utilizedfocus group interviewing triangulated with field obser-vation methods. A convenience sample of 13 nursingaides participated in two focus groups, and two aideswere shadowed for 16 hours. Field notes and tran-scripts were content-analyzed, and themes describingthe perspectives of aides were identified.

Results. Three themes were identified in the data: 1)‘‘We’re the eyes and the ears,’’ 2) ‘‘We know the pa-tient down to a tee,’’ and 3) ‘‘But we have no voice.’’Aides perceived being front-line care providers andfirst responders to emergent problems. In the process,they also formed close personal relationships with pa-tients and caregivers. However, aides perceived theircontributions to care and relationships with the familyas under-recognized by the IDT, and described overtand systematic marginalization of their roles and skills.

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Structural inequality was also verified on clinicalobservations.Conclusion. This disconnect between direct contactwith patients and families and perceived marginaliza-tion by the IDT created resentment among some aidesand an attitude of resignation among others.Implications for Research, Policy orPractice. Despite their perceptions of their contribu-tions to hospice care, aides felt undervalued by theirfellow team members. Hospice aides are essentialmembers of the IDT, and they represent a vulnerableworkforce. Better integration of hospice aides mayimprove team collaborations in patient care, impactthe retention of a skilled and essential workforce,and impact patient and caregiver support andoutcomes.

The Role of Nurse Gaze in Patient-NurseInteraction During Routine Intensive Care UnitCare (S703)Kim Frier, MSN ACHPN CFNP, The Ohio State Uni-versity, Columbus, OH. Margaret Crighton, PhD,The Ohio State University, Columbus, OH. MaryBeth Happ, RN PhD, The Ohio State University Col-lege of Nursing, Columbus, OH.

Objectives� Describe a typology of nurse gaze in routine ICUcare.

� Analyze inter-rater reliability (IRR) for thedifferent nurse gaze.

Original Research Background. Non-vocalcommunication is a vital aspect of human interactionfor establishing meaning, trust, and credibility be-tween communicators. Eye gaze is essential in face-to-face interactions regulating turn taking, attentionseeking, and conversation organization. Providergaze signals engagement or disengagement of pa-tient participation in health interactions. However,there is little empirical data on the role of gaze in in-teractions with patients in the ICU who are at highrisk of dying.Research Objectives. The purpose of this study is todescribe the role of gaze in communication with non-vocal, critically ill patients in the intensive care unit (ICU).Methods. Patients were adults >21 y.o., awake,arousable, able to communicate by head nods ormouthing words, and non-vocal due to endotrachealintubation or tracheostomy. Nurses were 10 volun-teers from a medical ICU and a cardio-thoracic sur-gical ICU participating in the usual care cohort ofthe Study of Patient-Nurse Effectiveness with Assis-ted Communication Strategies (SPEACS) study.Research method is a secondary analysis using qual-itative description and constant comparison of

video-recorded interactions between 10 nurse-pa-tient dyads. Inter-rater reliability (IRR) was assessedwith a second trained coder.Results. A typology consisting of four nurse gazes wasidentified: Listening, Assessing, Technical Doing, andRelating. Technical Doing (54%) and Listening (18%)gazes were the most frequently occurring in the sam-ple. Rater agreement ranged from 71-100% per videosession with an overall agreement of 87%. We calcu-lated agreement between raters for each gaze categoryfor 13 videos: Technical Doing 71%, Listening 63%,Assessing 58%, and Relating 90%.Conclusion. Technical Doing and Assessing gazefocus on the nurse. Listening and Relating gaze aremutual, collaborative gaze with patients. Relatinggaze, less frequently observed, may signal patient-nurse relationship development.Implications for Research, Policy or Practice. Atypology of nurse gaze in routine ICU care begins toexplicate the subtle intricacies of nurse-patient inter-action in patients at high risk for dying.

Reduced Length of Hospital Stay of an EmergencyDepartment Is Associated with an EarlyPalliative Care Team Interconsultation Strategy(S704)Andr�e Filipe Junqueira Dos Santos, MD PhD, ClinicsHospital of the Ribeirao Preto Medical School, Cravin-hos, Brazil.

Objectives� Demonstrate that early palliative care decreasedtime of hospital stay.

� Create an easy tool to measure of the perceptionof palliative care at an emergency department,the Awareness Index.

Original Research Background. Previous studiesreport that early palliative care (EPC) is associatedwith clinical benefits, but there is limited evidenceabout the impact on patients in an emergency. Werecently introduced an EPC strategy in a tertiary refer-ence emergency department (ED).Research Objectives. The aim of this study was toevaluate the impact of timing of palliative care inter-consultation on boarding time of patients.Methods. Clinical cohort of 281 adult patientsadmitted to ED due to aggravation of chronic condi-tions in need of palliative care. The attending physi-cian determined the need of palliative careinterconsultation. The time between arrival in EDand the consultation by the palliative care team wasdefined as Awareness Index (AI), and the time be-tween the first consultation and hospital dischargewas defined as Resolution Index (RI). The inpatienttime (IT) was the sum of SI with RI.

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Results. 121 women/160 men, mean age 64.14�16.3.The aggravated chronic conditions were neurologicaldiseases (116, 41%), advanced cancer (72; 25%), de-mentia (23, 8%), multiple comorbidities (18, 6%),serious chronic liver disease (7, 2%), chronic obstruc-tive pulmonary disease (10; 3%), and others (35,12%). We noted an increase of the number of patientsevaluated since the beginning of the project (13 until45/month). Lower IT was strongly associated withlower SI (p<0.01).

Conclusion. Palliative care interconsultation strategyduring emergency department admission is associatedwith lower length of ED stay for patients admitted withacute aggravated, chronic conditions.

Implications for Research, Policy orPractice. These findings showed the need to trainemergency physicians on palliative care since aware-ness of the importance of an early palliative careteam intervention in ER was associated with shorterlength of stay.

Sustaining Large-Scale, Direct-ObservationResearch in the Natural Setting: The PalliativeCare Communication Research Initiative CohortStudy (S705)Robert Gramling, MD DSc, University of Rochester,Rochester, NY. Sally Norton, RN PhD FPCN FAAN,University of Rochester, Rochester, NY. Wendy Ander-son, MD MS, University of California San Francisco,San Francisco, CA. Elizabeth Gajary-Coots Universityof Rochester, Rochester, NY. Jenica Cimino, BA, Uni-versity of California San Francisco, San Francisco,CA. PCCRI Study Group.

Objectives� Acquire increased awareness of direct-observationresearch.

� Identify one approach for sustaining research-clinical team collaboration in direct-observationresearch.

Original Research Background. Understanding thecharacteristics of communication that foster patient-centered outcomes amid serious illness is essentialfor the science of palliative care. However, epidemio-logical cohort studies that directly observe clinicalconversations can be challenging to conduct in thenatural hospital setting.

Research Objectives. We describe the successfulenrollment, observation and data collection methodsof the ongoing Palliative Care CommunicationResearch Initiative (PCCRI).

Methods. The PCCRI is a multi-site (Rochester, NYand San Francisco, CA) cohort study of naturallyoccurring inpatient palliative care consultations. The6-month cohort data includes directly observed and

audio-recorded palliative care consultations (up tothe first three visits); patient/proxy/clinician self-report questionnaires both before and the day afterconsultation; post-consultation, in-depth interviews;and medical/administrative records.

Results. One hundred seventy patients (10% byproxy) and 45 palliative care clinicians enrolled inPCCRI during the first 18 months of enrollment. Sev-enty percent of eligible patients (adults with advancedsolid cancer, English speaking, and not enrolled inhospice at time of referral) were invited to participate,and 60% of them ultimately enrolled, resulting in anoverall 42% sampling proportion. The PCCRI success-fully oversamples for minority/under-represented pa-tient populations.

Conclusion. Epidemiologic study of patient-family-clinician communication in palliative care settings isfeasible and acceptable to patients, proxies and clini-cians. We detail the successful PCCRI methods forenrollment, direct observation, and data collectionfor this complex ‘‘field’’ environment.

Implications for Research, Policy orPractice. Results from this work will provide theempirical basis for understanding, measuring anddisseminating high-quality communication in pallia-tive care settings.Dr. Gramling is representing the full PCCRI WritingGroup on this abstract solely due to limitations inspace for multiple-authorship. This work is fundedby a Research Scholar Grant from the American Can-cer Society (PI: R. Gramling)

Comparing the Pharmacokinetics ofRectally Administered PhenobarbitalTablets in Microenema Form VersusSuppository (S706)Bradford Macy, BSN RN CHPN, Kaiser PermanenteHospice, Concord, CA. Y. W. Francis Lam, PharmD,University of Texas Health Science Center at San An-tonio, San Antonio, TX. Anson Lam, MD, WCCTGlobal, Fullerton, CA.

Objectives� Describe this research study including the objec-tives, methods, results and conclusions.

� Describe the implications of this study within thecontext of clinical practice and need for futureresearch.

Original Research Background. The oral route iscompromised for nearly all patients approachingdeath. When agitation or other intractable symp-toms occur, an effective, reliable and comfortablealternate route for medication delivery that iseasy to administer in the home setting is highlydesirable.

Vol. 51 No. 2 February 2016 409Poster Abstracts

Research Objectives. To characterize the early ab-sorption profile, variability, and comfort of phenobar-bital tablets given in a microenema suspensiondelivered via the Macy Catheter� (MC) versus thesame dose given via suppository.Methods. This was a randomized, open-label, cross-over study comparing the early absorption profile ofequal doses of phenobarbital administered rectally inthree treatment phases: phenobarbital suppositoryand two different microenemas with phenobarbitaltablets crushed and suspended in 6ml (MC-6) and20ml (MC-20) of tap water.Results. Mean plasma phenobarbital concentrations at10 min were 12x higher for MC-20 and 8x higher forMC-6 compared to suppository. Concentrationsachieved in 30 minutes via MC-20 took almost 3 hoursto achieve with suppository. Mean AUC values werehigher for MC-20 and MC-6 (82% and 46%, respec-tively) vs. suppository (P < 0.05). There was less vari-ability in absorption for MC-20 and MC-6 (1.4 to1.9-fold difference) compared to a 4.4-fold differencevia suppository. MC administrations were reported as‘‘not uncomfortable’’ compared to suppositories, whichwere reported as ‘‘mildly uncomfortable’’ (P < 0.05).Conclusion. The absorption kinetics of Macy Cath-eter-administered phenobarbital microenemas weresuperior to compounded phenobarbital suppositories,including rate of early absorption, overall absorption,variability, and comfort of administration.Implications for Research, Policy or Practice. Theadministration of micro-enemas with a rectal accessdevice such as the Macy Catheter could play an impor-tant role in the rapid control of symptoms related toagitation, seizures, and intractable suffering in thehome setting, allowing more patients to die peacefullyin the environment of their choice. Further researchwould be beneficial to better understand the potentialrole of microenema-delivered medications in symp-tom control.

Quality-of-Life (QoL) in Patients with AdvancedSolid Tumors as a Screening Tool During Phase IClinical Trial RecruitmentdProspective PilotStudy on Implications on Eligibility (S707)Sidra Anwar, MD, State University of New York at Buf-falo, Buffalo, NY. Grace Dy, MD, Roswell Park Cancerinstitute, Buffalo, NY. Wei Tan, MA, Roswell Park Can-cer Institute, Buffalo, NY.

Objectives� Recognize QoL as a predictor for serious adverseeffect (SAE) occurrence in patients enrolled inphase I oncology clinical trials.

� Recognize the importance of interdisciplinaryapproach when dealing with the oncologypatient.

Original Research Background. Despite physiciansattempts to select the ‘‘fittest’’ of subjects for phase Ioncology trials using rigorous inclusion/exclusioncriteria, many patients still suffer from serious adverseevents (SAEs) that lead to increased morbidity andmortality.Research Objectives. To assess whether baselinequality-of-life (QoL) scores can predict increased like-lihood of SAEs in patients and hence aid investigatorjudgment in deciding patient fitness for phase Istudies.Methods. 92 patients with solid tumors were includedin this analysis after enrolling in one of 23 phase I solidtumor clinical trials at a comprehensive cancer centerin Buffalo, NY. QoL questionnaires (FACT-G, EORTCQLQ-C30 and Medical Outcomes Study Social SupportSurvey) were administered at baseline. All SAEs thatoccurred within the first four cycles of treatment wererecorded. Fisher’s exact test was used to study the asso-ciation between categorical variables. A linear transfor-mation was used to standardize QoL scores. P-value #0.05 was considered statistically significant.Results. Mean age of the patients was 61 years, and41% were male. Baseline EORTC QLQ-C30 scoreswere poorer among patients who encountered SAEs(p ¼ 0.01). When EORTC QLQ-C30 scores werefurther analyzed according to specific domains, worseglobal health status, functional, and symptom scoreswere each associated with occurrence of SAEs (p ¼0.05, 0.03 and 0.02, respectively).Conclusion. Baseline EORTC QLQ-C30 score is asso-ciated with risk of SAEs during phase I trial therapy inpatients with advanced solid malignancies. Additionalstudies are needed to validate this observation andassess efficacy of interventions, such as early palliativecare, that might mitigate the risk for SAE in thispopulation.Implications for Research, Policy orPractice. Patients with otherwise favorable ’’tradi-tional’’ inclusion criteria may still be at an increasedrisk for SAEs due to their baseline QoL, a previouslyunrecognized predictor of adverse events in these tri-als. This study supports change in current phase Ieligibility protocols used for enrollment.

Ethnic Differences in Advance DirectiveCompletion and Care Preferences Over Time(S708)Jaclyn Portanova, BS, University of Southern Califor-nia Davis School of Gerontology, Los Angeles, CA. Su-san Enguidanos, MPH PhD, University of SouthernCalifornia, Los Angeles, CA.

Objectives� Identify differences in advance directive comple-tion rates among ethnic minority groups.


� Identify differences in care preferences amongethnic minority groups.

Original Research Background. Studies have docu-mented lower advance directive (AD) completionamong minority groups. Among those with ADs,blacks are more likely than whites to prefer aggressivecare. Little is known about how and if these differ-ences in preferences have changed over time.

Research Objectives. This nationally representativestudy aimed to investigate if differences in AD devel-opment persisted after adjusting for SES, health con-ditions, and religious involvement. Year of death wasanalyzed to see how AD completion changed overtime. For those with an AD, we investigated the associ-ation between these factors and electing aggressivecare.

Methods. We used data from the 2000-2012 Healthand Retirement Study (HRS) exit interviews, with fam-ily members of 8552 decedents included in the anal-ysis. Analyses included step-wise logistic regression todetermine the relationship between ethnicity andAD completion and preferences for aggressive careand how it changed over time.

Results. Overall, 42.8% (n¼3658) decedents hadcompleted an AD. Whites had the highest prevalenceof AD completion at 51%, Hispanics and blacks at16%. Additionally, 24.4% of blacks completing anAD elected prolonged care compared to 14.4% of His-panics and 3.6% of whites. Blacks and Hispanics eachhad 73% lower odds of completing an AD. Other fac-tors associated with completing an AD includedincreased age, more than high school education, be-ing widowed, higher SES, cancer, and attending reli-gious services. For blacks, AD completion increasedover time.

Conclusion. Blacks and Hispanics had significantlylower rates of AD completion than whites. Blackswho completed ADs were more likely to opt for aggres-sive care. Model covariates had a relatively small influ-ence on ethnic differences. The odds of having an ADamong blacks increased for each subsequent deathyear.

Implications for Research, Policy or Practice. Theeffect of cultural differences in AD completion ratesamong minorities requires further investigation. Clini-cians should be aware of differences in treatment pref-erences and ensure they are honored.

Access to Hospice for Undocumented Immigrants(S709)Nathan Gray, MD, Duke University Hospital, Durham,NC. Kimberly Johnson, MD MHS, Duke University

Medical Center, Durham, NC. Rachna KuchibhatlaDuke University Medical Center, Durham, NC.

Objectives� Identify access challenges faced by undocu-mented immigrants seeking hospice services.

� Cite the availability of hospice enrollment for un-documented immigrants in a national sample.

� Identify characteristics of hospice agencies thatare associated with enrollment of undocumentedimmigrants.

Original Research Background. The 11 million un-documented immigrants in the U.S. are not coveredby the Medicare hospice benefit, and the majorityare uninsured. Little is known about access to hospicefor this population.

Research Objectives. To determine the availabilityof hospice care to undocumented immigrants.

Methods. Data for this study are from an ongoing na-tional study of hospices to determine best practices inoutreach to minorities. Via a web-based survey, wecollected data assessing hospices’ practices regardingenrollment of undocumented immigrants. We usedfrequencies to summarize responses to individualitems and Chi-square to compare responses by hospicecharacteristics.

Results. Datawere available for 161hospices from fourU.S. census regions: South (N¼82, 50.9%), Midwest(N¼42, 26.1%), Northeast (N¼26, 16.2%), and West(N¼11, 6.8%). A majority (N¼92, 57.1%) reported of-fering unrestricted access to hospice for the undocu-mented. Many agencies (N¼35, 21.7%) offered accessbut placed restrictions on the number of patients, and12 (7.5%) reported that enrollment was not availableto undocumented patients; 22 (13.7%) did not knowif enrollment was available. Of the 97 hospices that re-ported their enrollment practices, 48.4% (N¼47) hadreceived a total of 149 requests and enrolled 137(91.9% of requests) patients. Hospices that were morelikely to enroll undocumented immigrants without re-striction were non-profit vs. for-profit (68.6% vs.21.6%, P¼<0.0001), had larger annual budgetsdgreat-er than $4 million (72.7% vs. 40.0%, P¼0.0003), andwere not affiliated with a chain (63.6% vs. 14.3%,P¼0.0002).

Conclusion. While a majority of hospices enrolledundocumented immigrants, many limited the numberof patients enrolled, and a small number did notenroll undocumented immigrants. Unrestrictedenrollment was more common among large, non-profit, independent hospices.

Implications for Research, Policy or Practice.Changes in public policy that expand access to hos-pice for undocumented immigrants may improve thequality of care and reduce end-of-life care costs forthis population.


Naloxegol for Treating Opioid-InducedConstipation n Patients with Non-Cancer Pain(S710)Corie Shoop, PharmD, Astrazeneca PharmaceuticalsLP, Wilmington, DE. Yiqun Hu, MD PhD, Astrazeneca,Wilmington, DE.

Objectives� Become familiar with the safety and efficacy pro-file of naloxegol as a treatment for opioid-induced constipation in patients with chronicnon-cancer pain.

� Understand the mechanism of action of peripher-ally acting mu-opioid receptor antagonists andhow this method of action differs from that ofstandard laxatives.

Original Research Background. Opioid-inducedconstipation (OIC) affects 40%e80% of patientsreceiving opioids to manage chronic non-cancerpain, which can negatively impact quality of life andeffective pain management. OIC results when opioidagonist effects at mu-opioid receptors in the entericnervous system reduce gastrointestinal (GI) transitand secretions. Over-the-counter laxatives are oftenineffective. Naloxegol is an approved, orally adminis-tered, peripherally acting mu-opioid receptor antago-nist (PAMORA) that specifically targets themechanism of OIC.Research Objectives. To summarize phase 3 clinicaltrial data for naloxegol.Methods. Data were reviewed from two phase 3randomized, double-blind, 12-week studies con-ducted in outpatients with non-cancer pain andOIC (KODIAC-04, [NCT01309841]; KODIAC-05,[NCT01323790]) and a 52-week, phase 3 safety study(KODIAC-08 [NCT01336205]).Results. KODIAC-04 (n¼652) and KODIAC-05(n¼700) compared the efficacy (primary endpoint:response over 12 weeks) and safety of daily admin-istration of naloxegol 12.5 or 25 mg vs. placebo. Akey secondary endpoint included the 12-weekresponse rate in laxative users with OIC symptoms.Both studies reported significantly higher responserates for naloxegol 25 mg vs. placebo in the overallpopulation and among laxative users with OICsymptoms. KODIAC-08 (n¼844) compared thesafety and tolerability of naloxegol with usualcare, and demonstrated a long-term safety profilesimilar to that seen in the 12-week studies. In allthree studies, most common adverse events (AEs)on naloxegol were GI AEs, which occurred earlyin treatment, were mild or moderate in severity,and resolved during treatment or after discontinua-tion. Pain scores and opioid doses remained stable.The mechanism of action of naloxegol will bediscussed.

Conclusion. Naloxegol is a safe and efficacious treat-ment for OIC in adults with chronic non-cancer pain.Implications for Research, Policy orPractice. Clinicians may consider naloxegol therapyfor patients with chronic non-cancer pain reportingOIC.

A Systematic Review of Subcutaneous MedicationDosing Guidelines in Palliative Care (S711)Michael Hurst, MD, University of Alabama Birming-ham, Birmingham, AL. Neal Steil, MD, University ofAlabama Birmingham, Birmingham VA, Birmingham,AL.

Objectives� Understand the appropriate use and dosingranges of palliative medications delivered subcu-taneously, based on available literature.

� Develop an understanding of how common med-ications can be delivered by a novel, subcutaneousroute.

Systemic Review Background. Subcutaneous medi-cation administration has been a mainstay of palliativecare for several decades, offering multiple advantagesover both IV and PO administration in many cases.The evidence for conventional administration routesis more developed than for that of the same medica-tions given subcutaneously. Subcutaneous comfortmedication use has not been standardized, administra-tion being determined primarily by clinical experi-ence. While this method of practice can be usedwith reasonable efficacy, particularly in experiencedclinicians, there is a need for evidence-based practicesto be developed as reference for more standardizedcare.Aims. The aim of our systematic literature review wasto assimilate the published information for subcutane-ous administration of 10 commonly used medicationsin palliative practice, creating a resource of accepteddosing guidelines.Methods/Session Descriptions. A comprehensiveliterature review of major databases was performedfollowing PRISMA guidelines. Attempts were madeto include any published literature that included adescription of subcutaneous dosing practices formorphine, levetiracetam, ranitidine, metoclopramide,dexamethasone, furosemide, haloperidol, glycopyrro-late, fentanyl, and midazolam. Relevant articles werereviewed, and data on subcutaneous dosing were re-corded. Ranges of the studied medications that hadbeen administered safely and efficaciously werecompiled.Conclusion. While there is a dearth of objective dataand a lack of FDA approval for subcutaneous adminis-tration of most of the medications commonly used inpalliative care, an attempt has been made to create a


consensus on best practices for administering thesemedications. In addition to contributing to patientsafety, these guidelines may help expand the usageof comfort medications to a wider variety of drugs,enabling ease of administration across a multitude ofsettings.

They Said on the Death Certificate . . . But ReallyWhat I Think Happened.: CharacterizingCause of Death in VA Medical Centers (S712)Beverly Williams, PhD MA, University of Alabama atBirmingham and Birmingham Veterans Administra-tion Medical Center, Birmingham, AL. F. Amos Bailey,MD FACP FAAHPM, Denver Health/University of Col-orado, Denver, CO. Patricia Goode, MD MSN, Univer-sity of Alabama at Birmingham, Birmingham, AL.

Objectives� Learn about next-of-kin’s perspectives on whydeath occurred for patients receiving care in VAMedical Centers and the importance family mem-bers place on how the patient died.

� Learn about the types of circumstances in whichnext-of-kin do not agree with the official causeof death for patients who died in VA MedicalCenters.

Original Research Background. Nearly 20,000 Vet-erans die each year in VA facilities. The VA iscommitted to providing next-of-kin with accurate in-formation about the patient’s end-of-life care andcause of death.

Research Objectives. We examine next-of-kin’s ac-counts of Veterans’ hospital care during the last daysof life to explore how family members characterizecause of death.

Methods. In 2005-2010, we interviewed 78 next-of-kinof deceased Veterans in six VA Medical Centers. Weused content analysis to explore next-of-kin’s charac-terization of cause of death and to identify circum-stances in which family members disagreed with theofficial cause on the death certificate.

Results. In next-of-kin’s accounts, death rarely wasattributed to a single cause. Instead, next-of-kindescribed death as a sequence of events or an under-lying process involving the interaction of physiolog-ical, psychosocial, and transcendent aspects of thepatient’s life. Cause of death often was characterizedin terms of how the patient died rather than whythey died. Next-of-kin tended to question the officialcause of death in the setting of multiple morbidity, un-disclosed medical conditions, and sudden death whenfamily members were not present.

Conclusion. For next-of-kin, reducing cause of deathto a single designation on the death certificate beliesthe physical, emotional, social, and spiritualcomplexity of the patient’s circumstances. Instead,

next-of-kin characterize cause of death as a series ofevents or a process with mode of death as a salientcomponent. Multiple morbidity, undisclosed medicalconditions, and sudden death without family presencecan lead to contested cause of death.

Implications for Research, Policy orPractice. Appreciation of assumptions and circum-stances shaping next-of-kin’s perceptions of cause ofdeath can inform medical professionals’ communica-tion with family members. Characterizing death as aprocess and acknowledging the importance familymembers place on how the patient died can enhancethe efficacy of cause of death discussions. Findingshave relevance for policies shaping the context ofpost-death patient/family-centered clinical practice.

Do Palliative Care and Geriatric Factors Predict6-Month ER Use in Older Jail Inmates? (S713)Jessica Humphreys, MD, University of California, SanFrancisco, San Francisco, CA. Cyrus Ahalt, MPP, Uni-versity of California, San Francisco, San Francisco,CA. Brie Williams, MD, University of California, SanFrancisco, San Francisco, CA.

Objectives� Understand geriatric conditions and symptomburden in a population of recently incarceratedolder adults.

� Understand rates of 6-month ER utilization in thispopulation.

� Discuss the potential appropriateness of utilizinga geriatric palliative care paradigm to improvesymptom management and reduce ER use.

Original Research Background. Increasingly, geri-atric palliative care aims to target interventions tochronically ill patients with physical and psychosocialsuffering prior to the end of life. Among older adults,geriatric palliative care can improve distressing symp-toms and reduce ER use. Older jail inmates are arapidly growing population with disproportionatelyhigh rates of multimorbidity, pain, and ER use, yetthe appropriateness of geriatric palliative care forthis population is unknown.

Research Objectives. Identify the relationship be-tween geriatric and palliative care factors and ER usein older jail inmates.

Methods. Six-month longitudinal study of 101 jail in-mates aged 55 or older. Predictors of ER use includedsociodemographics; health conditions; pain (BriefPain Inventory); non-pain physical distress (MemorialSymptom Assessment Scale), psychosocial symptoms(depression [PHQ-2], anxiety [GAD-2]), loneliness(3-item Loneliness Scale); functional impairment (dif-ficulty with Activity of Daily Living) Montreal Cogni-tive Assessment (MOCA) score <27, and post-releasesafety concerns. We used X2 tests and multivariate


logistic regression to identify factors associated withER use.Results. Mean age of participants was 60, 65% wereblack, 61% had multimorbidity, 57% were functionallyimpaired, and 85% scored <27 on the MOCA. At base-line, 52% reported pain, 53% experienced physicaldistress, 37% reported psychological distress, and46% reported loneliness. At 6 months, 44% used theER; 21% visited multiple times. Factors associatedwith ER use included pain (p<0.001), functionalimpairment (p¼0.02), loneliness (p¼0.04), multimor-bidity (p¼0.006), and safety concerns (p¼0.002). Af-ter adjustment, pain (p¼0.02) and safety concerns(p¼0.04) remained associated with ER use.Conclusion. Rates of 6-month ER use in older jail in-mates are similar to those of older adults in the lastyear of life. Symptomatic distress (loneliness, pain)and geriatric conditions (functional impairment, mul-timorbidity, safety concerns) are associated with ERuse.Implications for Research, Policy or Practice. Jailis an important setting to test geriatric palliative careparadigms in an effort to minimize suffering anddecrease ER use in older inmates.

Integrated Geriatrics and Palliative MedicineFellowships: Training Future Leaders to Meet theDemographic and Workforce Needs (S714)Helen Fernandez, MD MPH, Icahn School of Medi-cine at Mount Sinai, New York, NY. Elizabeth Linden-berger, MD, Icahn School of Medicine at Mount Sinai,New York, NY. Sandra Sanchez-Reilly, MD FAAHPM,University of Texas Health Science Center, San Anto-nio, TX.

Objectives� Discuss the benefit of training fellows in an inte-grated program with dual expertise in geriatricsand palliative medicine.

� Describe the potential benefits of combined andcompetency-based training programs.

� Summarize position funding strategies, educa-tional methods and special professional develop-ment trainings used by integrated programs ingeriatrics and palliative medicine.

Original Research Background. It is clear thatthere is a demographic imperative with the agingand chronically ill population growing at a steadyspeed. Geriatrics and palliative medicine are similarin many aspects, such as an emphasis on inter-profes-sional teams and promoting function, quality of life,and advance care planning. Since both fellowshipsare a one-year clinical programs, trainees are ill-pre-pared to enter the academic world.Research Objectives. We proposed an integratedgeriatric-palliative medicine fellowship (integrated

fellows¼IF) that will meet the core competencies re-quirements in 16 months and allow for 8 months ofprofessional development focusing on leadershipskills.Methods. We designed an integrated curriculum al-lowing fellows protected time to develop compe-tencies in either research, education oradministration, improving leadership training and ad-dressing public health needs. The programs weremodified by taking advantage of several overlappingrequirements, such as home care and decreased thenumber of inpatient and outpatient rotations, to focusmore on academic development. In 2012, AmericanBoard of Internal Medicine (ABIM) approved a com-petency-based pilot at the Icahn School of Medicineat Mount Sinai, and in 2014, University of TexasHealth Science Center at San Antonio was approvedas the second site. ABIM supported pilot programswith faculty development and tools in competency-based assessments. Academic production wasmeasured by number of national presentations, spe-cial professional development trainings achieved,and current jobs plans.Results. As of July 1, 2015, we have graduated sixIFs and enrolled 13 new IFs. To date, IFs have pre-sented 19 abstracts at national meetings andcompleted 15 professional development trainings,and 100% of IFs have pursued academic-leadershipcareers.Conclusion. This competency-based fellowship hasgiven fellows more opportunities to develop skillsthat will prepare them for faculty or leadershippositions.Implications for Research, Policy or Practice. IFtraining programs may foster the development ofleaders in both fields due to the overlapping of com-petencies and serve as a model for other potential col-laborations.

Advance Directives Among Nursing HomeResidents with Mild, Moderate and AdvancedDementia (S715)Jennifer Tjia, MD MSCE, University of MassachusettsMedical School, Worcester, MA. Marisa Dharmawar-dene, MD MPH, University of Calgary, Calgary, AB.Jane Givens, MD, Hebrew Rehabilitation Center, Bos-ton, MA.

Objectives� An understanding of which demographic factorsare most likely to impact completion of advancedirectives in nursing home residents withdementia.

� An understanding of which clinical stages of de-mentia are most likely to be associated withadvance directives among nursing home patients.


Original Research Background. For nursing homeresidents with complex care needs, particularly thosewith dementia, advance directives (ADs) provideessential guidance around medical decision-making.Identifying factors affecting AD completion is crucialto improving patient-centered care and efficiency ofcare in this population.

Research Objectives. To describe the prevalence ofADs among nursing home residents with mild, moder-ate, or advanced stage dementia and resident factorsassociated with ADs.

Methods. We constructed a cohort of nursing homeresidents from five states in the U.S. (Minnesota,Massachusetts, Pennsylvania, Florida, California) in2007 and 2008. Residents were identified and assessedusing the Minimum Data Set 2.0 (MDS) linked toMedicare claims (Parts A and D) and the Medicaredenominator file. Eligible residents were aged 65and older and had a duration of stay $90 days anda diagnosis of dementia and a Cognitive PerformanceScale (CPS) score $ 1. Stage of dementia was classi-fied using the CPS. ADs were defined as the presenceof a living will; do-not-resuscitate order (DNR); or do-not-hospitalize (DNH) order, medication restriction,and feeding restriction. Logistic regression was usedto identify resident characteristics associated with ADs.

Results. The final sample size was 226,926. Overall,forty percent (n¼91,547) had no AD. Presence ofDNR, DNH, feeding restriction and medication re-striction orders increased with dementia severity. Inadjusted analysis, older age, female sex, white race,higher education, and being married or widowedwere associated with the presence of an AD (all p’s< .001).

Conclusion. ADs are more common among nursinghome residents with advanced stages of dementia.Presence of ADs is influenced by a number of demo-graphic factors.

Implications for Research, Policy orPractice. This study adds to growing evidence identi-fying factors influencing AD completion. A greater un-derstanding of how such factors impact care planningwill help address barriers to patient-centered care forthis population.

Hospice Admission Following Community-Based,Specialist-Level Palliative Care: Incidence,Timing and Predictors (S716)Alexa Riggs, MPHc, Metropolitan Jewish Health Sys-tem (MJHS), New York, NY. Brenda Breuer, PhDMPH, Metropolitan Jewish Health System (MJHS)Institute for Innovation in Palliative Care, New York,NY. Lara Dhingra, PhD, Metropolitan Jewish HealthSystem (MJHS) Institute for Innovation in PalliativeCare, New York, NY. Jack Chen, MBS, Metropolitan

Jewish Health System (MJHS)Institute for Innovationin Palliative Care, New York, NY. Helena Knotkova,PhD, Metropolitan Jewish Health System (MJHS)Institute for Innovation in Palliative Care, New York,NY.

Objectives� Understand the rate of hospice conversion dur-ing long-term interdisciplinary, community-basedpalliative care, and describe the sociodemo-graphic and clinical factors that predict thisconversion.

� Understand sociodemographic and clinical fac-tors that may predict hospice referral timing aftercommunity-based, specialist-level palliative careusing statistical evidence.

Original Research Background. Community-basedpalliative care is emerging to support seriously illhomebound patients. Timely referral to hospice is akey objective. Interdisciplinary palliative care modelsmay provide repeated opportunities to facilitateappropriate hospice admission. We conducted a retro-spective cohort analysis of a large sample to explorehospice utilization after enrollment in one suchmodel.

Research Objectives. To evaluate the incidence andtiming of hospice conversion after enrollment in apalliative care program.

Methods. Patients (n¼1505) were enrolled during2010-2013 in a community-based, ‘high-touch’ modelof specialist palliative care that included home visitsby an MD/NP and social worker, telephonic outreachby an RN specialist, and access to 24/7 on-call care.Data entered into an electronic medical record atthe time of service were extracted for this analysis.Outcomes included hospice admission (yes/no) andduration of palliative care enrollment, and covariatesincluded sociodemographics, diagnosis, KarnofskyPerformance Status (KPS), referral source, and insur-ance status.

Results. The sample had a mean age of 71.6 years(SD¼14.5) and was 58.7% women, 32.9% White,29.8% Black, and 28.5% Hispanic. The mean lengthof stay (LOS) in the palliative care program was 310days; median was 210 (range 1-1589). A total of 334 pa-tients (22.2%) were admitted to hospice. In multivar-iate analysis, predictors of hospice admission wereshorter LOS in palliative care (p<0.001), cancer diag-nosis (p<0.001), lower KPS (p<0.001), and lowerpoverty level (p¼0.03). The only significant predictorof a longer LOS was higher KPS (p<0.01).

Conclusion. During months of care by a ‘high-touch’palliative care model, about one-fifth of patients wereadmitted to hospice, and relevant predictors of thisoutcome included cancer diagnosis, lower perfor-mance status, and higher socioeconomic status.


Implications for Research, Policy orPractice. Additional studies are needed to establishbenchmarks for hospice conversion in varied types ofcommunity-based palliative care programs.

The Interdisciplinary Hospice ‘‘Healing theHealer Group’’: A Qualitative Study of the Effectsof a One-Year Pilot Educational Program (S717)Gowri Anandarajah, MD, Brown University, Provi-dence, RI. Kristina Conner, MD, Warren Alpert Medi-cal School of Brown University, Providence, RI.Patricia Stebbins, MPPM MA, Memorial Hospital ofRhode Island, Pawtucket, RI.

Objectives� Understand the theoretical basis for this educa-tional program’s design and implementation.

� Understand the common themes present in thecases presented by the participants in the Healingthe Healer Group.

� Understand the effects of the program on partic-ipants, including both benefits and challenges.

Original Research Background. Healthcareworkers, including hospice providers, are at risk forcompassion fatigue and burnout. Few workplace inter-ventions are described and evaluated in the literature.Research Objectives. This study aims to evaluate 1-year outcomes of a pilot educational program de-signed to foster professional formation and decreaseburnout in interdisciplinary hospice providers.Methods. Educational approach: We developed the‘‘Healing the Healer Group’’ program for hospice pro-viders, drawing from medical education, chaplaincy,social work and nursing literature. Key design ele-ments: learning through reflection on practice, focuson complex patient/family interactions, healingthrough storytelling, learning from peers, safety, andsupport. The 1-hour small group format includes:relaxation exercises, discussion of a spontaneous‘‘case’’ by a participant, group reflection, and sharingof best practice approaches to challenges. In July,2014, we began monthly groups for clinicians (RNs,MSW, chaplains, MD) and a separate group for hos-pice aids. Evaluation: A multi-method qualitativeapproach included analysis of session field notes, writ-ten feedback after 6 months, and a semi-structured in-dividual participant interviews after 1 year. Qualitativeanalysis, conducted by three researchers, uses the im-mersion crystallization method. IRB approvalobtained.Results. All hospice team members have participated.Interviews will be completed by September 2015. Anal-ysis is ongoing. Themes in cases include: watchingsuffering, boundaries, emotional attachments, feelingalone, control, and dealing with chaos. Interviews andwritten feedback to date reflect learning and growth

through the program. Themes include: rich experi-ences, value of safe space to ‘‘deal with difficult prob-lems,’’ power of learning from colleagues (‘‘mindexpanding’’), and ‘‘uninterrupted story telling is heal-ing.’’ Format strengths: small group size, safety, spon-taneous cases, and skillful facilitation. Challenge:protected time. All participants recommendcontinuing the program.Conclusion. This pilot Healing the Healer Group ap-pears to have the potential fill a significant need in theprofessional lives of hospice workers.Implications for Research, Policy orPractice. Program expansion with further study isneeded.

Pilot of ‘‘Honoring Choices Wisconsin’’ in anAcademic Center: Navigation, Engagement andOutcomes (S718)Wendy Peltier, MD, Medical College of Wisconsin, Mil-waukee, WI. Fabian Johnston, MD MHS, Medical Col-lege of Wisconsin, Milwaukee, WI.

Objectives� Understand the key features of the ‘‘HonoringChoices’’ format for advanced care planning(ACP).

� Review the strategies for implementation of thismodel in the ambulatory setting in patients withadvanced cancer and potential outcomes of suc-cessful completion of the program.

Introduction. ‘‘Honoring Choices (HC) Wisconsin’’is an initiative, sponsored by the Wisconsin MedicalSociety, that utilizes an advanced care planning(ACP) framework modeled after the ‘‘RespectingChoices’’ program. The goal of HC is to make facili-tated and standardized ACP conversations part ofroutine medical care.Objectives. Pilot the feasibility of the ‘‘HonoringChoices’’ in a tertiary setting and to measure theimpact of program completion on patient outcomes.Methods. Over eight months, a team of physicians,nurses, social workers and chaplains underwent facili-tator training and implemented the HC qualityimprovement process. Oncology patients (inpatientand ambulatory) of four Cancer Center physicianswere targeted for inclusion. Demographics, processmeasures, and outcomes included workflows, time inconsultation, facilitator and patient satisfaction, pa-tient location of death, and DNR status.Results. HC was offered to 64% (294/460) of pa-tients. Facilitator conversations were scheduled for101 patients; 95 were documented in the medical re-cord. Completed advanced directive documents wereobtained from 41 patients. Facilitators reported highsatisfaction with the process. Findings included lowutilization of ACP tools in the medical record and


considerable RN coordination of care for clinic work-flows. Conversations averaged 30 minutes, andcompletion of documents happened more frequentlywithin the inpatient than ambulatory setting. Thirtypatients died since completion of the pilot, of which40% (n¼12) had accepted HC and had completedadvance plans. Compared to the non-HC group, theHC group was more likely to spend their final daysin hospice care (91.7% vs. 55.6%, p¼0.199).

Conclusions. HC provides a mechanism for culturechange around ACP with substantial impact on pa-tients and providers. Our pilot suggests implementa-tion is feasible yet requires considerable change inworkflows and resource allocation. Patients whocompleted HC were more likely to have a location ofdeath consistent with expressed wishes.

Getting to the Heart of the Matter. Results froma Regional Survey of Hospice ProvidersRegarding the Care of Patients with AdvancedHeart Failure (S719)Renee Holder, PharmD BCPS CPE, MedStar Washing-ton Hospital Center, Washington, DC. Kathryn Walker,PharmD BCPS CPE, MedStar Health, University ofMaryland School of Pharmacy, Baltimore, MD. JoanPanke, NP MA ACHPN, MedStar Washington HospitalCenter, Washington, DC. Anne Kelemen, MSW, Med-Star Washington Hospital Center, Washington, DC.J Hunter Groninger, MD FAAHPM, MedStar Washing-ton Hospital Center, Washington, DC.

Objectives� List perceived barriers to the care of patients withadvanced heart failure in hospice settings.

� Identify opportunities to improve the care of pa-tients with advanced heart failure in hospicesettings.

Original Research Background. Advanced heartfailure (HF) therapies, including inotropes and ven-tricular assist devices (VADs), may temporarilyimprove symptoms, function, and longevity for selectpatients. However, the role of these therapies in hos-pice care has not been well defined. This study was de-signed to describe the variation in practice as a needsassessment in improving care for advanced HFpatients.

Research Objectives. To describe the attitudes ofhospice providers related to caring for patients withadvanced HF therapies.

Methods. At an advanced HF summit held at Med-Star Washington Hospital Center, an 18-item multi-ple-choice survey was distributed to metropolitan DCarea hospice leaders in May 2015. Survey topicsincluded demographic information about the hospice(census, HF population, services), experience caringfor HF patients (such as presence of clinical

algorithms, coverage for inotrope therapy), and opin-ions about barriers and preferences for training. Re-sponses were analyzed using descriptive statistics.Results. Nineteen hospice leaders were representedat the summit and completed the survey (100%response rate). Respondents were in administrative(11/19) and clinical (11/19) leadership roles. Mostrespondents felt access to hospice for HF patientswas adequate/somewhat adequate (13/19), buttiming of referrals was too late (18/19). Fifteen(79%) respondents reported not having algorithmsfor HF management. Ten (53%) respondents re-ported inotropes were cost prohibitive. Of those,90%felt that that they would cover inotrope costs if theywere comparable to the cost of parenteral opioids.Fourteen (74%) respondents reported lack of experi-ence with inotropes, and 18 (95%) indicated interestin clinical training/support.Conclusion. As a result of this survey, we identifiedlack of experience, cost, and late referrals as barriersto providing advanced therapies for HF in a hospicesetting.Implications for Research, Policy orPractice. Opportunities to improve care include clin-ical training, establishing clinical protocols, and co-management with advanced HF specialists.

Advance Care Planning and Its Influence on Life-Prolonging Treatments Before Patients’ Deaths(S720)Jooyoung Cheon, MSN RN, University of Maryland,Baltimore, MD.

Objectives� Comprehend the effect of advance care planning(ACP) on the decisions regarding life-sustainingtherapy (LST) before patients’ deaths.

� Identify demographic, socio-economic, and dis-ease-specific factors influence on final decisionsregarding LST before patients’ deaths.

Original Research Background. Advance care plan-ning (ACP) refers to the whole process of discussionof end-of-life (EOL) care for future medical careand usually includes living will (LW), durable powerof attorney for health care (DPAHC), and discussionregarding EOL care preferences with others.Research Objectives. This study aimed to determinethe impact of ACP on life-prolonging treatments(LPTs) before patients’ deaths.Methods. This study used data from the Health andRetirement Study Exit Interviews. The inclusioncriteria were patients 1) who were aged 50 and older,2) who died between 2000 and 2012, 3) who hadmade any decision regarding all possible care to pro-long life, and 4) who belonged to one of the followingfour groups: no ACP (group one), discussion only


(group two), discussion combined with DPAHC(group three), and discussion combined with DPAHCand LW (group four). The sample size was 2486. Multi-variable logistic regression was used to identify factorsassociated with LPTs.Results. The patients’ mean age of death was 79.9years. A quarter of patients received LPTs. This per-centage in each group was 20.2% in group one,18.2% in group two, 16.4% in group three, and45.3% in group four. Factors associated with LPTswere as follows: having discussion combined withDPAHC (group three), having discussion combinedwith DPAHC and LW (group four), African-American,high school graduation, having children who residewith patients, and having private insurance. Patientswho had all types of ACP were 76% less likely toreceive LPTs than patients who had no ACP (OR:.24, 95% CI: .17e.32).Conclusion. Patients who had more types of ACPreceived less treatment to prolong life. This result en-hances the importance of having all types of ACP.Implications for Research, Policy orPractice. Developing interventions to increasecompletion of all types of ACP is suggested.

I Had No Idea He Was Dying: Barriers toMeaningful Communication About Life-LimitingIllness (S721)Deborah Waldrop, LMSW MSW, University at Buffalo,Buffalo, NY. Jacqueline McGinley, MSW, University atBuffalo, University of Maryland.

Objectives� Understand the elements of and barriers tomeaningful and effective communication abouta terminal prognosis.

� Identify the important aspects of the advance careplanning (ACP) process from caregivers’perspectives.

Original Research Background. Communicationwith healthcare providers is critical for helping familycaregivers understand and manage changes from alife-limiting illness. The majority of surrogate deci-sion-makers for people who are critically ill want phy-sicians to discuss the prognosis even when they areuncertain. Knowledge of a dying person’s wishes arecentral in healthcare decision-making and may influ-ence the quality of care at life’s end contributing tobereaved caregivers’ coping and adaptation to loss.Research Objectives. The purpose of the study wasto explore bereaved caregivers’ perceptions of howthe nature of (1) communication with healthcare pro-viders and (2) advance care planning (ACP) influ-enced experiences at life’s end.Methods. The study design was exploratory and lon-gitudinal. The results of Time 1 in-depth interviews

with 108 bereaved caregivers whose loved one died 4months before while in hospice care are presented. In-terviews were audiotaped, professionally transcribed,and submitted to iterative qualitative data analysis. Fre-quencies and descriptive statistics were calculated.Results. Participants reported that 90% of those whodied had specific end-of-life wishes and 86% had awritten advance directive, yet 27% had some type oftreatment that was inconsistent with expressed wishes.56% reported having a family meeting; the formatsranged from brief hallway conversations to formalplanned interdisciplinary conferences. 50% of the par-ticipants rated the quality of the communication asless than clear, leaving them with unmet needs. Fourthemes illustrated the elements of poor providercommunication: (1) insufficient information, (2)inappropriate location, (3) insensitivity, and (4) avoid-ance of the terminal prognosis.Conclusion. Family caregivers need providers toinitiate conversations about a terminal trajectory andguidance to help them prepare for an approachingdeath.Implications for Research, Policy orPractice. Sound communication and ACP honoringpatients’ wishes involves the honest presentation ofprognosis, options for care, and emotional sensitivityin an interdisciplinary environment that facilitatescomprehension.

Characterizing End-of-Life Care for Uninsuredand Undocumented Immigrant Patients in a CityHospital Center (S722)Janeen Marshall, MD, Icahn School of Medicine atMount Sinai, New York, NY.

Objectives� Identify characteristics and patterns of utilizationof uninsured and undocumented patients inneed of palliative care services.

� Identify care gaps in palliative care delivery to un-documented and uninsured patients and areasfor intervention, such as policy or systemschanges.

Original Research Background. In 2014, the WorldHealth Organization (WHO) mandated that access topalliative care and hospice be accessible for all. Carefor uninsured and undocumented (UAU) patientscontinues to be a struggle for health systems in theUS. Limited data is available regarding palliative careand hospice services for these patients.Research Objectives. To characterize the provisionof service, clinical course and outcomes for UAU pa-tients in need of palliative care and hospice services.Methods. Clinical and demographic data from UAUpatients followed by the Palliative Care Consult Service(PCCS) at Elmhurst Hospital Center from 12/1/2013


to 11/30/2014 was obtained. Undocumented statuswas indicated on the initial intake form. Diagnoses,reason for consult, length of stay, PCCS interventionsand discharge disposition were analyzed.

Results. 428 patients were referred to the PCCS.40.2% were 18-65 years old, and 59.8% were >65 yearsold. 49.8% were female. Approximately 11% of thesepatients died within 2 days of completion of theirPCCS consultation. 14% of patients were identifiedas UAU. More than 1/3 of these patients returnedhome with no palliative care services due to undocu-mented status and returned frequently to ED forsymptom exacerbations. The most common reasonfor consult for these patients was discharge plan-ning/placement, and for four of these patients, the ul-timate disposition was remaining in the city hospitaluntil their death due to their lack of insurance andtheir undocumented status.

Conclusion. To date, very little data on the experienceof undocumented and uninsured patients existsoutside of anecdote and case report. Characterizingthe end-of-life care in the uninsured and undocu-mented patients provides much needed data to helphospital systems provide palliation and discharge toappropriate care systems for this vulnerable population.

Implications for Research, Policy orPractice. Characterization of care for this vulnerablepopulation allows for identification of policy and sys-tem changes that may allow palliative care to reachthis vulnerable patient population.

Randomized, Double-Blind, Placebo-ControlledStudy of Methylphenidate for Treatment ofDepression in Cancer Patients Enrolled inHospice or Receiving Palliative Care (S723)Donald Sullivan, MD MA, Oregon Health & ScienceUniversity, Portland, OR. Linda Ganzini, MD MPH,Veterans Administration Portland Health Care System,Portland, OR. Elizabeth Goy, PhD, Veterans Adminis-tration Portland Health Care System, Portland, OR.Solange Mongoue-Tchokote, MS, Knight Cancer Insti-tute, Portland, OR. Motomi Mori, PhD, OregonHealth & Science University, Portland, OR.

Objectives� Understand the efficacy of methylphenidate fordepression treatment in cancer patients receivinghospice or palliative care.

� Understand the safety of methylphenidate fordepression treatment in cancer patients receivinghospice or palliative care.

Original Research Background. Major depressivedisorder can be diagnosed in up to 49% of patientswith advanced cancer. This disorder causes sufferingand is associated with suicidality and increased pain.Traditional antidepressants in cancer patients in

hospice or receiving palliative care are complicatedby shortened life expectancy, as they take several weeksto reach effectiveness. Methylphenidate has been re-ported in case series as a rapidly effective treatmentfor depression.Research Objectives. To determine the safety andefficacy of methylphenidate for depression treatmentin cancer patients receiving hospice or palliative care.Methods. An 18-day randomized, double-blind clinicaltrial of methylphenidate for depression in eligible pa-tients with advanced cancer whowere enrolled in hospiceor receiving palliative care. Patients were randomized toreceive methylphenidate plus a selective serotonin reup-take inhibitor (SSRI) versus placebo plus SSRI.Results. In total, 46 patients were enrolled, however14 were excluded before randomization or did notreceive study drug. At day 18, 84.6 % of the methyl-phenidate and 60% of the placebo group were indepression remission (p ¼ NS), which was measuredas a >50% reduction in score on the clinician-ratedMontgomery-Asberg Depression Rating Scale. Meantime to remission of depression was 10.3 days (SE1.77) in the methylphenidate and 8.1 days (SE 1.31)in the placebo group (p ¼ 0.38, log rank test).HADS scores from baseline to day 18 were not statisti-cally different between the two groups. Methylpheni-date was well tolerated with few side effects, andmortality was not different between the two groups.Conclusion. This clinical trial was unable to supportthe primary hypothesis that methylphenidate de-creases depression in cancer patients in hospice orreceiving palliative care. Low enrollment and higherthan anticipated remission rates impacted compari-sons. Methylphenidate was well tolerated with fewside effects in this patient population.Implications for Research, Policy orPractice. Our study underscores the difficulties in con-ducting randomized controlled trials for symptomman-agement in patients with shortened life expectancy.

Measurement of Pain and Health-Related Qualityof Life Measures in Adult Males withHemophilia: Initial Observations of DiseaseImpact (S724)Katharine Batt, MD MSc, Wake Forest UniversityBaptist Medical Center, Winston-Salem, NC. MarceloBonomi, MD, Wake Forest School of Medicine, Win-ston-Salem, NC. Christopher Walsh, MD PhD, MountSinai School of Medicine, New York, NY.

Objectives� Understand the type of painful symptoms experi-enced by the hemophilia population.

� Understand that pain impacts not only the phys-ical joint, but has consequent effects on themental health of the hemophilia patient.


Original Research Background. Hemophilia is a raregenetic bleeding disorder characterized by acute, painfulbleedsaswell as chronic arthropathy.Nostandardizedrec-ommendations exist to measure pain and its subsequentimpact on health-related quality of life (HRQoL) mea-sures in adult patients with hemophilia (PWH).Research Objectives. To assess pain and HRQoL inadult PWH treated at Mount Sinai Hemophilia Treat-ment Center (MSHTC) using a hemophilia-specificsurvey tool.Methods. All English-speaking adult male PWH >18years old who were treated at MSHTC received theHRQoL assessment instrument to complete either bymail at home or during a clinic visit.Results. 38/144 (26%) PWH completed the ques-tionnaires, with 27/35 (77%) completed at home.Of 13 joints surveyed, the most commonly reportedjoints and degree of pain were: right knee 16/19(84%), left ankle 16/17 (94%), right elbow 16/17(94%) and left knee13/15 (87%). In PWH, 14/34(41%) reported the most frequent cause of jointpain was from bleeding episodes; 13/34 (38%) re-ported chronic joint pain as the cause. 34/34(100%) of PWH reported daily pain without medica-tion; 15/31 (48%) reported no pain after the injectionof factor. 15/32 (47%) of PWH experienced theirworst pain symptoms at night; 11/32 (34%) reportedtheir worst pain in the morning. Only 9/34 (26%)PWH reported no impact of pain on their daily activ-ities. 21/31 (60%) of PWH reported painful symptomswere a direct cause of ‘‘low spirits’’ over the past year,with 8/35 (23%) of PWH reporting frequent to con-stant symptomatology.Conclusion. Assessment of pain and HRQoL demon-strates a high burden of unmeasured and untreatedsymptoms in PWH.Implications for Research, Policy orPractice. PWH suffer from acute and chronic painwith resultant effects on HRQOL; methodologic assess-ment tools can uncover this and offer opportunities forimproved comprehensive symptom management.

Personal Growth, Symptom Burden andUncertainty in Heart Failure (S725)Kristen Overbaugh, RN PhD, University of TexasHealth Science Center at San Antonio, San Antonio,TX. Mark Parshall, RN PhD, University of NewMexico, Albuquerque, NM.

Objectives� Define personal growth and explain its potentialrelevance to palliative care research.

� Understand levels of personal growth in adultswith heart failure.

� Examine relationships among personal growth,symptom burden, uncertainty, age, sex,ethnicity, time since diagnosis, and diseaseseverity.

Original Research Background. Heart failure (HF)is a chronic disease associated with unpredictabletrajectories, significant symptom burden, and dimin-ished quality of life (QOL). National guidelinesrecommend that palliative care (PC) be consideredin early stages of life-limiting chronic illnesses,such as HF. Personal growth (PG), which is the abil-ity to perceive positive psychosocial outcomesthrough significant adversity, is now being examinedin addition to QOL in people with serious illnesses,but it has been little studied in HF. Increases in PGhave been associated with improved QOL,morbidity, and mortality and decreased levels ofpain, fatigue, depression, and anxiety in otherserious illnesses.Research Objectives. To measure levels of PG inHF subjects and examine relationships among PG,symptoms, uncertainty, demographic and clinicalfactors.Methods. Subjects (N¼103) with NYHA class II-IV HFparticipated in this exploratory study. Measuresincluded the Posttraumatic Growth Inventory, MishelUncertainty in Illness Scale-Community Version, andMemorial Symptom Assessment Scale-HF.Results. Subjects reported moderate levels of PG(M¼48.6, SD¼28.62), symptom burden (M¼2,SD¼0.4), and uncertainty (M¼52.9, SD¼14.24). Oldersubjects reported less personal growth (r¼e.20,p<.05) and had more advanced disease (r¼.28,p<.01). Uncertainty was associated with moreadvanced disease (r¼.28, p<.01) and higher symptomburden (r¼.49, p<.01). Subjects with higher symptomburden reported greater PG (r¼.20, p<.05). Study var-iables did not independently predict PG in multivari-able models.Conclusion. Despite receiving evidence-based care,HF subjects only reported moderate levels of PG,and they still reported moderate symptom burdenand uncertainty related to their diagnosis, treatment,and the future. Facilitating PG may require psychoso-cial and spiritual support, traditionally lacking in stan-dard HF management.Implications for Research, Policy or Practice. HFpatients might benefit from earlier PC, which usesan interdisciplinary approach, integrates psychoso-cial and spiritual support, and focuses more explic-itly on symptom management. More studies areneeded to evaluate the need to measure and followPG among patients with chronic illnesses such asHF.


Bereaved Parents Experience of a HospitalMemorial Service (S726)Kathie Kobler, MS APN PCNS-BC, Advocate Chil-dren’s Hospital, Park Ridge, IL. Marilyn Barnes, MA,Advocate Lutheran General Hospital, Park Ridge, IL.

Objectives� Understand reasons a bereaved parent chooses toreturn to the hospital for a memorial service.

� Identify elements of a hospital memorial servicethat parents identify as most beneficial.

Original Research Background. 77% of children’shospitals participating in a palliative care survey re-ported offering a hospital-based memorial service(Feudtner, 2013), yet little is known about bereavedparents’ experiences of attending such a service.

Research Objectives. This paper reports prelimi-nary findings from an exploratory, qualitative studyto understand: why bereaved parents choose to attenda memorial service, what service elements parentsconsider most/least beneficial, and how a hospital me-morial service can best meet bereaved parents’ needs.

Methods. Parents experiencing a perinatal, neonatal,or pediatric death, and attending one of three yearlyhospital-based memorial services, were invited toparticipate (Current n¼15). In-person, semi-struc-tured interviews were conducted within one monthof memorial service attendance by a chaplainresearcher trained in supporting bereaved families; in-terviews were recorded and transcribed verbatim.Each interview was coded by two members of the inter-disciplinary research team using Atlas.ti7 for datamanagement. Thematic analysis was applied to eachfinal coded transcript, followed by analysis matricesdevelopment to look at major themes across parentinterviews.

Results. This study is in the last phase of data collec-tion, with final analysis projected by December, 2015.Emerging themes from 15 completed interviewsinclude: a sense of community with fellow bereavedparents and the importance of others joining the par-ents in remembering their child through ritual.

Conclusion. Bereaved parents who return to the hos-pital for a memorial service value the opportunity tohonor their child in a supportive setting. Parentsreport finding comfort in connecting to their childthrough memorial service ritual.

Implications for Research, Policy orPractice. Future research is needed to understandthe ongoing impact of memorial service attendanceon bereaved parents, including rituals they maychoose to adopt or continue after returning home.Children’s hospitals are encouraged to establish orfurther refine memorial services in support of grievingparents.

Feudtner, et al. (2013). Pediatric palliative careprograms in children’s hospitals. Pediatrics, 132(6),1063-1070.

Oncology Providers’ Perceptions of Early/Concurrent Palliative Care (S727)Dilip Babu, MD, University of Alabama at Birming-ham, Birmingham, AL. James N. Dionne-Odom,PhD RN ACHPN, University of Alabama at Birming-ham, Birmingham, AL. Lisa Zubkoff, PhD, GeiselSchool of Medicine at Dartmouth, White River Junc-tion, VT. Tasha Smith, PhD MPH, The University ofAlabama at Birmingham, Birmingham, AL. Marie Ba-kitas, DNSc CRNP AOCN ACHPN FAAN, Universityof Alabama at Birmingham, Birmingham, AL.

Objectives� Describe perceptions of palliative care amongdiverse populations of healthcare providers,including oncologists.

� Describe the development and validation of anoriginal survey instrument.

Original Research Background. Despite consensusopinion that early integration of palliative care is anessential component in the care of cancer patients,specialist palliative care remains poorly integratedinto standard oncology care. Oncologists’ attitudesand perceptions towards specialist palliative care mayplay a key role in successful or poor integration, how-ever this relationship has undergone little systematicstudy.

Research Objectives. To characterize oncology pro-viders’ perceptions of early/concurrent palliative care.

Methods. Based on literature review and expert feed-back, we systematically developed a survey to measureoncology providers’ perceptions of palliative care. Thesurvey was administered electronically, fromNovember 2014 to July 2015, to oncology providersat four southeastern U.S cancer centers where an earlypalliative care delivery model is being implemented.

Results. Thirty-six oncology providers completed thesurvey. Average age was 46; 42% were male (n¼15),and average time in practice was 13.4 years. 73%(n¼27) of respondents reported that oncologistsshould care for advanced cancer patients along withspecialist palliative care, and 27% (n¼10) endorsedthat oncologists alone should provide oncology andpalliative care. 92% (n¼34) reported that advancedcancer patients would benefit from early palliativecare, and 90% (n¼33) thought consulting with pallia-tive care specialists adds value to care. However, morethan 40% of respondents believed discussion of palli-ative care would cause patients and families to losehope and feel that ‘‘nothing more can be done.’’

Conclusion. Oncology providers generally believethat specialty palliative care benefits patients with


newly-diagnosed advanced cancer. The optimal timingand degree of palliative care involvement remain vari-able among providers.Implications for Research, Policy or Practice. Thesurvey will be re-administered to reassess oncologyproviders’ perceptions of early palliative care afterimplementation of the early palliative caredelivery model and to examine whether providers’perceptions are associated with successful palliativecare integration.

Oncology Massage Duration and Effects onSymptom Expression in Cancer Patients andCaregivers (S728)Gabriel Lopez, MD, University of Texas MD AndersonCancer Center, Houston, TX. Richard Lee, MD, Uni-versity of Texas MD Anderson Cancer Center, Hous-ton, TX. Kathrin Milbury, PhD, University of TexasMD Anderson Cancer C, Houston, TX. Yisheng Li,PhD, The University of Texas MD Anderson CancerCenter, Houston, TX. Lorenzo Cohen, PhD, The Uni-versity of Texas MD Anderson Cancer Center, Hous-ton, TX.

Objectives� Learn about benefits of oncology massage as amanual therapy for symptom relief, includingimpact of massage duration on symptomexpression.

� Understand the benefits of oncology massagerelated to both cancer patients and caregivers inthe outpatient setting.

Original Research Background. Massage as amanual therapy has shown benefit for symptomatic re-lief in cancer patients and their caregivers.Research Objectives. We explored the impact of asingle massage session on self-reported symptoms,including impact of massage duration on symptomexpression.Methods. Data were reviewed from massage sessions(30- or 60-min duration) at our Integrative MedicineCenter outpatient clinic (5/2011-12/2013). Partici-pants completed the Edmonton Symptom AssessmentScale (ESAS; 10 symptoms, 0-10 scale, 10 most severe)pre- and post-massage. ESAS subscales analyzedincluded Physical Distress (PHS, 0-60), PsychologicalDistress (PSS, 0-20), and Global Distress (GSD, 0-90).Baseline scores were compared (patient vs. caregiver)using Wilcoxon rank-sum tests. Pre/post score differ-ences were compared using 2-way ANOVA models.Results. 585 initial massage visits (491 patients; 93caregivers) were analyzed. Symptoms with highestscores (means) at baseline were the same for patientsand caregivers [sleep; fatigue; well-being]. ComparingESAS subscales (means) at baseline, there was no sta-tistical difference between patient and caregiver PSS

(4.08 vs 4.3; p¼0.6) or GSD (19.6 vs 15.9; p¼0.06);PHS was significantly different (12.4 vs 8.4;P¼0.001). GSD was significantly reduced after a singlemassage for both patients (19.60 to 12.45; p<0.001)and caregivers (15.92 to 10.78; p<0.001). For anxietyonly, caregivers experienced a significantly greaterreduction than patients [-1.91 vs -1.30; p¼0.03]. Look-ing at all participants, a 60-min massage resulted in asignificantly greater improvement in anxiety, well-be-ing, and GSD than a 30-min massage (all p’s # 0.005).Conclusion. A single 30- or 60-min massage sessionresulted in acute relief of self-reported symptoms inpatients and caregivers.Implications for Research, Policy orPractice. Further study is warranted regarding neces-sary dose (duration, frequency) of massage to main-tain effective symptom control.

Efficacy of Acupuncture (ACU) Therapy forCancer-Related Pain Management in OncologyPatients (Pts) (S729)Jai Patel, PharmD, Levine Cancer Institute, Charlotte,NC. Connie Edelen, MD FAAPMR, Carolinas Health-care System, Charlotte, NC. Katherine Miller LevineCancer Institute, Matthews, NC. James Symanowski,PhD, Levine Cancer Institute, Charlotte, NC.

Objectives� Understand the role of acupuncture in cancersymptom management.

� Identify characteristics of oncology patients andcancer symptoms that respond favorably withacupuncture.

Background. Cancer-related pain negatively affectssymptom burden, morbidity, and mortality. Evidencesuggests the use of ACU to relieve cancer-relatedpain. We investigated ACU efficacy and patient-spe-cific factors associated with pain improvement.Methods. Medical charts were reviewed fromoncology patients receiving ACU and concurrent palli-ative medicine management. Pre- and post-ACU painscores, as assessed by the Edmonton Symptom Assess-ment Scale (ESAS), were measured at each session.Univariate logistic regression models, including anover-dispersion parameter to account for multiple ob-servations per patient, were used to investigate the as-sociation between patient-specific variables (Table 1)and significant pain improvement, defined as a $ 2-point reduction in ESAS pain score, at each session.Results. A total of 122 ACU sessions from 53 patientswere included in the analysis. Significant painimprovement was observed in 47% of all sessions(mean reduction 1.8). Baseline non-neuropathicpain was significantly associated with a higher oddsof achieving pain reduction (OR 2.351; P¼0.047).Conversely, an opposite association was identified for


baseline neuropathic pain (OR 0.421; P¼0.048). Age,stage, number of sessions and tumor type were notsignificantly associated with pain improvement,although several trends were noted (Table 1).

Conclusions. ACU is an appropriate adjunct therapyfor cancer-related pain, particularly for non-neuro-pathic pain. Larger studies to confirm patient-specificvariables and further investigation into therapyrelated side effects will assist in determining apersonalized approach to ACU therapy in theoncology population.

The Power of a Plan: The Impact of PalliativeCare Decisions at Hospital Discharge onReadmission Rates (S730)Joshua Fabie, MSII, Georgetown University, Washing-ton, DC. Kathryn Walker, PharmD, BCPS CPE, Med-Star Health, University of Maryland School ofPharmacy, Baltimore, MD. Christopher Kearney, MD,MedStar Health, Ellicott City, MD.

Objectives� Describe the differences in hospital readmissionrates and associated charges between patientswith a palliative plan of care and no palliativeplan at discharge.

� Describe the differences between early/lateconsultation and the plan of care on the indexadmission charges.

Original Research Background. Hospital readmis-sion (RA) rates are recognized as a marker of qualityand tied to hospital reimbursement. This study de-scribes the impact of early palliative care (PC) consul-tation in the hospital and the discharge plan of careon the rate of RA for PC patients.

Research Objectives. 1) To compare RA rates andcharges for patients choosing a PC plan versus non--palliative plan post-hospitalization. 2) To compare dif-ferences in hospital charges between earlyconsultations and plans of care.

Methods. All patients receiving PC consultation andsurviving to discharge in three Baltimore hospitals(12/12-4/13). Financial reports, Social Security DeathIndex, and chart review were used for data collection.Palliative care plan of care (PCPOC) was defined aspost-discharge plans that focused primarily on com-fort (e.g., hospice), and non-palliative plans of care(NPPOC) represented usual care. Adjusted RA datarepresents only patients alive at each time-point. Earlyconsultations were performed #3 days on indexhospitalization.

Results. 180 patients were included in this study, and53% were consulted early. Overall, 64% agreed to aPCPOC at discharge. Index admission charges wereless for early consultations (D$22,566, p*) and forthose leaving the hospital with a PCPOC (p*). At 30days post-hospitalization, mortality was higher in thePCPOC group (80% vs 29%, p*), and overall RA rateswere higher in the NPPOC group (42% vs 7%, p*).When adjusted for mortality, RA rates were higher inthe NPPOC group (45% vs 21%, p). RA chargeswere higher per patient (D$7,031) and per RA(D$9,646) for the NPPOC group at 30 days.

Conclusion. PCPOC and early PC consultation areassociated with decreased hospital utilization.

Implications for Research, Policy orPractice. Future research should further determinethe impact of PCPOC and timing of PC consultationon hospital use and RA.

Pediatric Palliative Care Training in Fellowship:A National Survey of Adult Palliative MedicineFellowship Directors and Pediatric RotationDirectors (S731)Sonia Malhotra, MD MS, Ochsner Medical Center,Section of Palliative Care, New Orleans, LA. Robert Ar-nold, MD FAAHPM, University of Pittsburgh, Pitts-burgh, PA.

Objectives� Outline the current state of education and clin-ical training of adult hospice and palliative medi-cine (HPM) fellows in pediatric palliative care(PPC).

� Compare responses between adult HPM fellow-ship and pediatric rotation directors regardingthe future of PPC education and training.

Original Research Background. With only sevenpediatric palliative care (PPC) programs in the coun-try, there is a lack of PPC physicians. Large numbersof pediatric patients are cared for by palliative physi-cians trained in adult fellowships. Adult HPM fellow-ships require pediatric training, but little is knownabout what is taught and what educators’ thoughtsare about this training.

Table 1Univariate results

Covariate Odds ratio (95% CI) P-value

Age (>57 vs. #57 years)a 0.501 (0.206-1.219) 0.128IndicationNon-neuropathic pain

(yes vs. no)2.351 (1.012-5.459) 0.047

Neuropathic pain(yes vs. no)

0.421 (0.179-0.992) 0.048

Stage (3-4 vs. 0-2) 2.004 (0.791-5.075) 0.143Number of sessions (>3 vs. #3) 0.379 (0.125-1.152) 0.087Tumor typeb - 0.467a Median ageb Stratified by breast, gastrointestinal, genitourinary, thoracic, gynecologic,hematologic, neurologic, and other cancers, and analyzed as a categoricalvariable.


Research Objective. To describe adult HPM fellows’clinical and educational exposure to PPC.Methods. An electronic survey was sent to adult HPMfellowship directors and their respective pediatric rota-tion directors. The survey elicited information aboutPPC learning objectives, didactics, and fellows’ PPCclinical experience. Finally, directors’ attitudes aboutthe current and future state of PPC training was sur-veyed. Data was de-identified, and descriptive statistics,Chi-square, and sample t tests were analyzed.Results. 41 of 98 adult HPM fellowship directors and36 of 80 pediatric rotation directors responded(response rates 42% and 45%, respectively). Most pro-grams indicated their fellows spend time observingPPC teams manage symptom and communication is-sues rather than independently managing patientswith supervision. For example, only 9 of 36 programsallowed adult fellows to independently convert opioidswith supervision. Fellowship and pediatric rotation di-rectors felt somewhat (46%) or very (17%) uncomfort-able with adult HPM fellows practicing PPC.Fellowship and pediatric rotation directors disagreedabout whether they would be likely to develop a pedi-atric track within their programs (p¼0.04).Conclusion. Most adult HPM fellows are observingPPC teams rather than learning to independentlymanage patients. Both groups of respondents indi-cated discomfort with adult HPM fellows practicingPPC.Implications for Research, Policy orPractice. This study highlights that pediatrics rota-tions need restructuring or elimination from adultHPM fellowships, and questions whether training ef-forts should be redirected towards pediatricians andpediatric subspecialists to fill the void of PPC physi-cians rather than development of pediatric tracks.

Existential Suffering in Advanced Cancer: TheBuffering Effects of Narrative (S732)Lucille Marchand, MD BSN BS FAAHPM, Universityof Washington School of Medicine, Seattle, WA.

Objectives� Describe My Living Story, a narrative, dignity-enhancing intervention for advanced cancerpatients.

� Appraise the effects of this intervention on exis-tential well-being and psychological distress.

Original Research Background. Dignity-enhancingtherapy is a narrative life review intervention shownto improve well-being in hospice and palliative carepatients. Our previous pilot study using a modifieddignity-enhancing, life-story intervention suggestedthat pre-hospice, advanced cancer patients couldbenefit from this intervention. This randomized con-trol trial was designed to test the effects of My Living

Story on existential wellbeing and psychologicaldistress in advanced cancer patients. My Living Storyincluded a life review interview, the delivery of thelife story, and online cancer information and personal-ized tools to revise and share the story with loved ones.Research Objectives.

1. Describe My Living Story, a narrative, dignity-enhancing intervention for advanced cancerpatients.

2. Appraise the effects of this intervention on exis-tential wellbeing and psychological distress.

Methods. 117 patients with stage 3 or 4 cancer wererecruited from the University of Wisconsin CarboneCancer Center and randomized 1:1 to My Living Storyor to an active control group with access to accurateonline cancer resources. Existential wellbeing was as-sessed with the FACIT-Sp subscales for peace and well-being, and the POMS-SF subscales for anger,depression, anxiety at baseline, 2 and 4 months afterintervention. Linear Mixed Model, controlling forpre-test, tested for group comparisons of repeatedoutcome measures and their subscales at 2 and 4months.Results. At four months, the intervention group hada significantly increased greater sense of peace (p¼.029) than the active control group. The interventiongroup had higher scores for existential wellbeing(p¼.096) and lower scores for depression (p¼.102)than the control group, whose scores worsened whilethe intervention group maintained or slightlyimproved.Conclusion. My Living Story, a modified Dignity-Enhancing Story program, improved advanced can-cer patients’ sense of peace and buffered againstthe worsening depression and existential wellbeingseen in the online cancer information controlgroup.Implications for Research, Policy or Practice. Thedignity-enhancing intervention studied by Chochinov,et al in hospice patients can have wider applicability toother palliative care patients in improving wellbeingand quality of life.

Developing a ‘‘Toolkit’’ for Implementing Early,Concurrent Palliative Care in Community CancerCenters (S733)Marie Bakitas, DNSc CRNP AOCN ACHPN FAAN,University of Alabama at Birmingham, Birmingham,AL. James N. Dionne-Odom, PhD RN ACHPN, Uni-versity of Alabama at Birmingham, Birmingham, AL.Dilip Babu, MD, University of Alabama at Birming-ham, Birmingham, AL. Elizabeth Kvale, MD, Univer-sity of Alabama at Birmingham Center for Palliativeand Supportive Care, Birmingham, AL. Lisa Zubkoff,


PhD, Geisel School of Medicine at Dartmouth, WhiteRiver Junction, VT.

Objectives� Gain greater knowledge of the process of how todevelop and test a measurement Toolkit for palli-ative care.

� Gain knowledge of instruments needed to effec-tively measure implementation of a palliativecare intervention.

Original Research Background. Under-resourcedcommunity cancer centers (CCCs) are at a disadvan-tage for implementing early palliative care (EPC) asrecommended by national guidelines. As part of anACS-funded implementation study, we were chal-lenged to evaluate four CCCs’ implementation ofthe evidence-based ENABLE (Educate, Nurture,Advise, Before Life Ends) EPC model. No EPC-specificimplementation measures exist; hence we developedand tested a measurement ‘‘Toolkit’’ to assess imple-mentation at study sites.

Research Objectives. To create and test a measure-ment ‘‘Toolkit’’ to evaluate pre- and post-ENABLE im-plementation using the RE-AIM (Reach, Effectiveness,Adoption, Implementation, and Maintenance)framework.

Methods. We undertook a measurement develop-ment process within an implementation study at fourracially-diverse CCCs in the Southeastern U.S.Following a literature search, expert panel assessment,and site stakeholder input and review, we developedfour measures to evaluate RE-AIM dimensions. Newlydeveloped instruments were pilot-tested during initialsite visits.

Results. 1) RE-AIM Self-Assessment Tool (13 items)completed by site staff that quantitatively and qualita-tively measures EPC program reach, adoption, imple-mentation, and maintenance; 2) the EPC GeneralOrganizational Index (interviewer ratings in 12 do-mains); 3) EPC Implementation costs-sites completefor start-up and on-going program implementationcosts; and 4) Oncology Providers Perceptions of EPC(29 items) measures clinicians attitudes about EPC.Patient and caregiver effectiveness is measured by vali-dated quality-of-life, symptom, and mood question-naires. We will present data on inter-rater reliabilityand content validity, and sample outcome data.

Conclusion. Implementing EPC is a professionalmandate. We have developed and tested and will bedisseminating an implementation measures ‘‘Toolkit’’that is feasible, with preliminary reliability and validity.

Implications for Research, Policy orPractice. Measuring whether program implementa-tion and dissemination has occurred is a critical anddeveloping area of implementation science that neces-sitates systematic collaboration among key

stakeholders: patient, family, clinician, program ad-ministrators, and implementation scientists.

Dignity Therapy Feasibility for Cancer PatientsUndergoing Chemotherapy (S734)Ann Dose, APRN RN, Mayo Clinic, Rochester, MN.Joleen Hubbard, MD, Mayo Clinic, Rochester, MN.Jeff Sloan, PhD, Mayo Clinic, Rochester, MN. PamelaMcCabe, RN PhD, Mayo Clinic, Rochester, MN.

Objectives� Explore issues associated with providing a pallia-tive care intervention simultaneously with activecancer treatment.

� Discuss preliminary outcomes of dignity therapyprovided to newly diagnosed pancreatic cancerpatients undergoing chemotherapy.

Original Research Background. Recent guidelinespromote provision of palliative care simultaneouslywith active treatment for advanced/metastatic cancers,including interventions addressing all quality-of-life(QOL) domains. Dignity therapy (DT) is an interven-tion demonstrating promising outcomes at end of life.It has not been offered to cancer patients during treat-ment nor paired with a life plan (LP) intervention.

Research Objectives. The purpose of this phase I/IIstudy was to determine the feasibility, acceptability andselected patient-reported outcomes of the dignity ther-apy/life plan intervention and to pilot study methodswith pancreatic cancer patients pursuingchemotherapy.

Methods. DT is a brief psychotherapeutic interven-tion consisting of a focused life review/values clarifica-tion delivered during three outpatient oncology clinicvisits. Interviews were audiotaped, transcribed, andedited to produce a Generativity Document, whichthe patient can later share with family. Life plan is atype of ‘‘bucket list,’’ wherein patients documentfuture hopes/dreams. Feasibility was evaluated,distress measured with the Distress Thermometer (0-10 scale) and QOL measured with the LinearAnalogue Self-Assessment (LASA, 0-10 scale). Baselinescores of distress and QOL were compared with scoresafter the intervention four to six weeks later (Time 2[T2]).

Results. Fifteen pancreatic adenocarcinoma patientswere approached, ten were enrolled, and ninecompleted all study procedures. Two-thirds were satis-fied/very satisfied with DT/LP, and 78% found studyparticipation worthwhile and DT/LP timing to bejust right, and they would recommend DT/LP toothers. QOL improved (baseline mean¼7.0;T2¼7.25). Distress scores improved (baseline mean¼6.13; T2¼5.63).

Conclusion. Distress and QOL modestly improvedfrom baseline to T2. Baseline scores were collected


before patients had begun any chemotherapy; there-fore, any improvements while undertaking aggressivechemotherapy are noteworthy. Participants felt theintervention was acceptable and better than they hadexpected.Implications for Research, Policy or Practice.Conducting DT/LP in an outpatient oncology chemo-therapy setting for newly diagnosed pancreatic cancerpatients is both feasible and acceptable. Outcomes areencouraging for future larger scale trials.

Hospice Caregiver Self-Care: Who’s Caring for theCaregiver? (S735)Monica Beck, MSN, University of Alabama Huntsville,Huntsville, AL. Lee Ellington, PhD, University ofUtah, Salt Lake City, UT. Catherine Dingley, RN FNPPhD, University of Nevada Las Vegas, Henderson,NV. Margaret Clayton, APRN PhD, University ofUtah, Salt Lake City, UT. Maija Reblin, PhD, H. LeeMoffitt Cancer Center, Tampa, FL.

Objectives� Describe five themes related to caregivers’ healthand well-being identified during communicationswith home hospice nurses.

� Discuss the importance of integrating caregiverhealth/well-being needs into a holistic family-centered approach during home hospice care.

Original Research Background. While caregivingburden varies over time, cancer caregivers reportlower quality of life and poorer health when providingend-of-life care than during active treatment. Care-giver needs are significant as they affect the qualityof caregiving and the likelihood of premature and un-necessary hospital admissions. Yet little is known aboutthe interaction between caregivers and hospice nursesregarding the caregiver’s health and well-being duringthis crucial time in the cancer care trajectory.Research Objectives. The purpose of this qualitativedescriptive study was to explore interactions betweencaregivers and hospice nurses related to caregivers’well-being, health, and self-care during in-home visitsfor advanced cancer patients.Methods. Audio recordings of hospice nurse/care-giver conversations (N¼60) were randomly selectedfrom a larger, multi-site study for analysis. 85% of care-givers reported one or more health problems (M¼2.5,SD¼1.3), yet only half of the visits had communicationfocused on the caregiver’s well-being, health, or self-care.Results. When discussed, communication related tocaregivers focused on the following themes: lack ofsleep or rest (caregivers’ and patients’ sleep patternswere intricately intertwined), physical effects of care-giving (other than sleep, such as back strain fromlifting), health maintenance issues, emotional/

psychological issues (feeling overwhelmed, ‘‘muddledand confused,’’ sharing/balancing family relationsand caregiving), and existential issues (bearing witnessto family member’s suffering, finding meaning in therole reversal of caregiving, preparing for death/loss).Conclusions. Caregivers experience multiple issuesrelated to their health/well-being that could be ad-dressed during home hospice visits, yet communica-tion is limited.Implication for Research, Policy, andPractice. Little is known about how to facilitate hos-pice family caregivers’ well-being, health, or self-care.While caregiver distress and psychological effectshave been studied, the physical aspects of caregivinghave rarely been included. Findings from this studyprovide the foundation for further research and prac-tice focused on ways to integrate caregivers’ healthand self-care needs into a holistic, family-centeredapproach during hospice care.

Factors Affecting Post-Acute Referrals forPalliative Home Health Care Among Patientswith End-Stage Heart Failure (S736)Susan Lowey, RN PhD CHPN, State University of NewYork College at Brockport, Rochester, NY.

Objectives� Identify three factors that affect referrals for palli-ative home health care.

� Identify which characteristics of the nurse (demo-graphics, education, nursing experience, per-sonal experience with palliative care) affectreferrals for palliative home health care.

Original Research Background. Patients with heartfailure have the highest rates of hospital readmissionsand comprise the largest percentage of home care ad-missions of any other group. Although palliative care(PC) has been shown to be an effective way to managedistressing symptoms in end-stage heart failure, pa-tients are infrequently referred to PC home carefollowing hospital discharge for an exacerbation.Research Objectives. The purpose of this study wasto examine factors that influence the care transitionsof end-stage heart failure patients to PC home care.Methods. Focus groups were held with home healthdischarge nurses to elicit qualitative data used todevelop a 45-item quantitative survey. The survey wasthen randomly distributed to home care nurses acrossNew York state.Results. A total of 112 respondents completed thesurvey. Two-thirds (69.2%) of the home care agenciesoffered PC services, while 30.8% only had hospice.87% of nurses felt they had the ability to refer patientsto the home PC team. Nurse age, years of experience,and education were not correlated with a greater num-ber of palliative care referrals, whereas personal


experience with PC was. 91% of nurses indicated aformal protocol for discharge planning.

Conclusion. Patients’ diagnoses were found to bemore closely associated with PC referrals than pres-ence of pain/symptoms or declining functional status.26% of nurses believed patients required a life expec-tancy of less than 6 months to qualify for PC.

Implications for Research, Policy orPractice. Findings from this cross-sectional pilotstudy suggest the need to refine discharge planningprotocols to better evaluate patients in need of PCprior to home care admission. The transition fromthe hospital to the home may be an ideal time to referpatients to palliative home care. Patients with end-stage heart failure may benefit from receiving pallia-tive home care by improving symptom managementat home which could also decrease hospital readmis-sions.

Development of Standardized Case Vignettes toAssess Palliative Care Professionals’ Recognitionof Delirium, Dementia, and Depression (S737)Stewart Bond, RN PhD AOCN, Boston College, Chest-nut Hill, MA. Sara Keary, PhD MSW, Boston College,Chestnut Hill, MA. Donna Fick, RN PhD, PennsylvaniaState University, University Park, PA.

Objectives� Describe a systematic process used in developingstandardized case vignettes of patients withdelirium, dementia, and depression in thecontext of palliative care.

� Examine palliative care professionals’ recognitionof delirium, dementia, and depression in patientswith advanced life-limiting illnesses.

Original Research Background. Timely and accu-rate diagnosis of delirium in palliative care is chal-lenging. Palliative care professionals often fail torecognize delirium because of its variable presentationand overlap with other conditions such as dementiaand depression.

Research Objectives. To develop and test standard-ized case vignettes to assess palliative care profes-sionals’ recognition of delirium, dementia, anddepression.

Methods. Case vignettes of patients experiencing hy-peractive, hypoactive, and mixed delirium; dementia;hyperactive delirium superimposed on dementia(DSD); hypoactive DSD; and depression were draftedand presented to 10 delirium experts who assessedcontent and construct validity. Revised vignettes werethen reviewed by a subset of four experts. Final vi-gnettes were incorporated into a web-based surveyand administered to an interdisciplinary panel of palli-ative care professionals, including physicians (n¼8),nurses (n¼7), and social workers (n¼5).

Results. More than 70% of experts agreed that eachvignette had an appropriate level of simplicity. At least80% agreed that each was very plausible. There wasmore variation regarding clarity. Correct diagnosticagreement (CDA) among the experts was at least90% for all but one vignette. In the second review,simplicity and plausibility were rated high, with100% CDA for all but one vignette. All palliative careprofessionals correctly identified depression. CDAwas 95% for dementia and hyperactive delirium and90% for hypoactive delirium. CDA was lower forboth hyperactive and hypoactive DSD (75%) andmixed delirium (70%).Conclusion. Overall, palliative care professionalsaccurately identified depression, dementia, and hyper-active and hypoactive delirium. They were less accu-rate in identifying mixed delirium and DSD.Implications for Research, Policy orPractice. Standardized case vignettes provide aninnovative approach for studying challenging phe-nomena such as delirium in palliative care. The vi-gnettes will be used in a larger study examiningpalliative care professionals’ recognition of delirium,dementia, and depression and in future studies toevaluate the effectiveness of educational interven-tions.

Cancer Symptom Scale Preferences: Does One SizeFit All? (S738)David Joyce, PhD, University College Dublin, Dublin,Ireland.

Objectives� Understand and appreciate how preferences forsymptom assessment instruments vary within acohort of cancer patients.

� Understand the clinical utility of symptom assess-ment instruments using the observer method.

� Understand the importance of incorporatingscale preference into practice of symptomassessment.

Original Research Background. Cancer patients donot report all symptoms readily, so assessment is bestdone systematically to ensure effective symptom man-agement. The completion rate of some symptom in-struments in the seriously ill is less than 50%.Research Objectives. Subjective symptom experi-ence can be quantified by various scales that includethe Categorical Response Scale (CRS), Numerical Rat-ing Scale (NRS), and Visual Analogue Scale (VAS).This study sought to determine patient preferencesfor CRS, NRS, and VAS in symptom assessment andtheir clinical utility in three common and importantcancer symptoms: pain, tiredness, and loss of appetite.Methods. A prospective survey was conducted.Consecutive eligible cancer admissions to a 36-bed


palliative care inpatient unit were invited to partici-pate. Preferences were elicited with regards to threesymptom assessment scales. Participants selected theirpreferred scale for each symptom. We also determinedthe clinical utility of each scale, defined by ease ofcompletion as judged by an observer. A total of 100 in-patients were recruited.Results. VAS was the least preferred measure. Scalepreference was highly consistent across symptoms.52% choose the same scale for all three, and 44%for two, with just 4% choosing a different individualscale for all three. There was moderate agreement be-tween participant scale preference and observer-deter-mined ease of scale completion (Pain: K ¼ 0.49;Fatigue: K ¼ 0.45; Appetite loss K ¼ 0.36).Conclusion. VAS were the least popular. Most partic-ipants had a specific scale preference with high intra-patient consistency between the three scales. CRS waspreferred for appetite loss and tiredness, but NRS forpain.Implications for Research, Policy orPractice. Based on these findings, clinicians and re-searchers involved in cancer symptom assessmentshould consider individualized use of scales directedby patient preference. As the scale with both the lowestpreference score and observed clinical utility, VASshould be used with great caution in this population.

Pilot Findings from Aware CompassionateCommunication: An Experiential ProviderTraining Series (ACCEPTS) for Palliative CareProviders (S739)Sean O’Mahony, MD MS, Rush University MedicalCenter, Chicago, IL. James Gerhart, PhD, Rush Uni-versity Medical Center, Chicago, IL. Ira Abrams,MEd, Shambhala Meditation Center of Chicago, Chi-cago, IL. Michelle Greene, PhD, Rush University Med-ical Center, Chicago, IL.

Objectives� Increase awareness of symptoms of burnout andPTSD in Palliative Medicine Health CareProviders.

� Describe ACCEPTS protocol for enhanced Psy-chological Flexibility.

Original Research Background. Although manyproviders enter palliative medicine with the intentionof helping others, working in this practice also requiresthat providers will be repeatedly exposed to the pain,trauma, and death of their patients. These experiencesmay threaten the values of providers and evoke a rangeof avoidant coping behaviors that potentiate distressand erode the quality of care provided.Research Objectives. This manuscript reports pilotfindings from Aware Compassionate Communication:An Experiential

Provider Training Series (ACCEPTS) for PalliativeCare Providers that is derived from principles of Psy-chological Flexibility Theory.Methods. Twenty-one providers participated in agroup-based 8-week, 10-session training series thatemphasized mindfulness and acceptance-based inter-ventions as applied to the needs of those workingwith the chronically ill and dying. Participantscompleted measures of distress (i.e. depressive symp-toms, burnout) and the PTSD symptom checklist(PCL-C), and they also proposed mechanisms ofchange identified by Psychological Flexibility Theory(i.e. cognitive fusion and experiential avoidance) atpre-training, mid-training and post-training. Signifi-cant reductions in depressive symptoms, depersonal-ization-burnout, and cognitive fusion were observed.Results. At baseline, the PCL score was 26, above theat-risk range for PTSD. Participants reported prac-ticing mindfulness on average approximately 139minutes per week. There were significant improve-ments in cognitive fusion (p¼.025), symptoms ofdepression (p¼.007), and levels of re-experiencing(a symptom of PTSD) (p¼.011) and depersonalization(a symptom of Burnout) (p¼.001).Conclusion. Results indicated that ACCEPTS is anacceptable and feasible intervention for providersthat may enhance well-being. More research is neededto assess cognitive fusion as a potential mechanism ofchange in the program.Implications for Research, Policy or Practice. Itcould improve workforce resiliency, well-being, and re-tention.

Loss and Bereavement in Adolescent and YoungAdult Oncology Patients (S740)Liza-Marie Johnson, MDMPH MBE, St. Jude Chil-dren’s Research Hospital, Memphis, TN. Justin Baker,MD FAAHPM, St. Jude Children’s Hospital, Memphis,TN.

Objectives� Describe the prevalence of loss in adolescents andyoung adults (AYA), and list the sources of sup-port used by AYA following loss.

� Summarize the impact of loss on AYA.� Use the bereavement questionnaire to screen forsignificant loss.

Original Research Background. Bereavement is theobjective situation of losing someone significantthrough death and the subsequent adjustment thatfollows. This phenomenon is not well described inadolescent populations, particularly among thosewith an increased risk of mortality due to a life-threat-ening illness.Research Objectives. To quantify the prevalence ofloss and describe the bereavement experiences of


adolescent or young adult (AYA) who are alsooncology patients.

Methods. Cross-sectional survey study of AYA (age 13-21) with diagnosis of malignancy or life-threating he-matologic disorder requiring allogeneic transplant.

Results. 153 AYA (95% participation) enrolled in thestudy. The majority (87.5%) identified at least oneloss, and 65% identified the significant loss of a per-son (n ¼100). The most common losses were grand-parent (58%), friend (37%), or pet (35%). Adiagnosis of leukemia or myeloproliferative or myelo-dysplastic disease was associated with an increased like-lihood of significant loss (p ¼ 0.047). Individualsrating a loss as highly significant were more likely toendorse that the loss changed their life enormously(p < 0.0001) and that recovery was slow or they ‘‘nevergot over it’’ (p < 0.0001). Even when the loss was ratedhighly significant, only a minority of AYA discussed thelosses often (23%), with the majority speaking about itsometimes (43%) or rarely/never (34%).

Conclusion. The majority of AYA will experience lossand often identify the death as significant. AYA arelikely to have bereavement experiences that are slowor ongoing, yet they infrequently discuss the losswith others. The impact of loss appears greatest inAYA who endorse significant loss (9 or 10) on a simple1-10 Likert scale. Use of the Likert scale appears to bea simple screen for identifying significant loss in AYAwho are oncology patients.

Implications for Research, Policy orPractice. Loss is common in AYA, and their griefand bereavement experiences remain understudied.Evidenced-based research and increased clinicalscreening are needed in this population.

The Intensive Palliative Care Unit (IPCU):Changing Outcomes for Hospitalized CancerPatients in an Academic Medical Center (S741)Haipeng Zhang, DO, Dana-Farber Cancer Institute,Boston, MA. Constance Barysauskas, MS, Dana-FarberCancer Institute, Boston, MA. Charlotta Lindvall, MDPhD, Massachusetts General Hospital, Boston, MA.Elizabeth Rickerson, MD, Dana-Farber Cancer Insti-tute/Brigham & Women’s Hospital, Boston, MA. Ka-thy Selvaggi, MD MS FAAHPM, Dana-Farber CancerInstitute, Boston, MA.

Objectives� Describe the unique characteristics amongoncology patients admitted to the intensive palli-ative care unit (IPCU) at Dana-Farber CancerInstitute/Brigham and Women’s Hospital.

� Identify three outcomes of a highly specializedintensive palliative care unit.

� Discuss potential benefits of an intensive pallia-tive care unit for cancer patients.

Original Research Background. Patients withadvanced cancer often require complex symptommanagement. At Dana-Farber/Brigham and Women’sCancer Center, the intensive palliative care unit(IPCU) admits oncology patients with uncontrolledsymptoms throughout the trajectory of illness. ADNR/DNI is not required for admission. These pa-tients are managed by an interdisciplinary team ofpalliative care clinicians who focus on symptom man-agement and advanced care planning.

Research Objectives. The purpose of our analysiswas to investigate goals-of-care outcomes and health-care utilization after admission to the IPCU.

Methods. We retrospectively reviewed patient, diag-nosis, IPCU admission, and code status characteristicsamong 74 oncology patients admitted to the IPCU inAugust and September, 2013. We examined the distri-bution of goals of care pre- and post-index IPCUadmission.

Results. A total of 67 IPCU patients received pallia-tive chemotherapy and/or radiation, while seven pa-tients received curative intent treatment. All patientshad documented goals-of-care discussions during theIPCU admission. Of the palliative intent treatment pa-tients, 58% were transferred to the IPCU from medicaloncology and 42% were directly admitted. Eighty-seven percent of patients reported pain as the chiefcomplaint, and all patients documented multiplesymptoms (median ¼ two). Twenty-five patients(37%) experienced a change in code status fromFULL to DNR/DNI. A total of eight patients died inthe IPCU, and 50% of these experienced a code statuschange during the index admission. Eighty-eightpercent of patients were discharged alive. Of those,49% were discharged to home hospice, general inpa-tient hospice, or an inpatient hospice facility. Therisk of 30-day readmission was 4% (95% CI -1%-9%),adjusted for the competing risk of death.

Conclusion. Our findings suggest the inpatient palli-ative care unit helps clarify goals of care, aids in appro-priate hospice referrals, and decreases unnecessaryhospital readmissions among advanced cancerpatients.

Implications for Research, Policy or Practice. AnIPCU may optimize advance care planning.

The Caregivers Like Me Telenovela Was Non-Inferior to the Chasing the Tiger Video inEducating Healthcare Professionals About End-of-Life (EOL) Care in Ethnically DiversePopulations (S742)Erica Schockett, MD, Saint Louis University School ofMedicine, Saint Louis, MO. Dulce Cruz-Oliver, MD,Saint Louis University, Saint Louis, MO. TheodoreMalmstrom, PhD, Saint Louis University, Saint Louis,


MO. Eric Cooney, BA, Saint Louis University, SaintLouis, MO. Michael Roegner, BS MA, Saint Louis Uni-versity School of Medicine, Saint Louis, MO.

Objectives� Describe the effect of caregivers’ and patients’cultural background on their attitude towardend-of-life care.

� Explore the concept of cultural competency andits application in healthcare worker trainings topromote better end-of-life care.

Original Research Background. Healthcareworkers serve increasingly diverse communities andface the challenge of delivering culturally responsiveend-of-life (EOL) care to patients and caregivers.There is no best practice for providing cultural compe-tency education in these settings. This calls for the cre-ation and evaluation of innovative training tools.Research Objectives. To investigate the effect of anewly developed telenovela, or video soap opera, onhealthcare workers’ awareness of caregivers’ stressand patients’ cultural approaches to EOL care.Methods. In a cross-sectional pre- and post-test study,participants (N¼144) from a convenience sample inNew York, Florida, and Missouri were voluntarily as-signed to view the control video or the interventiontelenovela as part of a one-hour presentationincluding information on cultural competency andhealth literacy.Results. Post-test responses demonstrated a highlevel (88%) of satisfaction with the seminar and an in-crease in openness to discuss EOL issues with cultur-ally diverse patients (p<.001) and to discuss(p¼.003) and support (p<.001) caregivers with stressin the control and intervention groups. Both groupsreported post-test improvement in knowledge of cul-tural competency skills and cultural differences aboutEOL attitudes (p<.001) with a tendency for superiorimprovement in the intervention group (p¼.053).Both groups better recognized the importance of care-giver burden and possible interventions (p<0.001),but their likelihood to discuss this with caregivers re-mained the same after the seminar (average 4.6, 1low-5 high).Conclusion. The intervention telenovela proved tobe as effective as if not superior to the control videoas an educational tool for healthcare workers in cultur-ally diverse care environments. Available in Englishand Spanish language versions, it expands the avail-able resources to help more EOL care providers servepatients with cultural humility.Implications for Research, Policy orPractice. Approaching cultural competency educa-tion for EOL care with tools based on culturally rele-vant values is a promising framework for educatinghealthcare professionals.

Using Measurement Invariance to Validate theMail and Phone Versions of the Bereaved FamilySurvey (BFS) (S743)Mary Ersek, RN FPCN, University of Pennsylvania,Philadelphia, PA. Joshua Thorpe, PhD MPH, Univer-sity of Pittsburgh School of Pharmacy, Pittsburgh,PA. Dawn Smith, MS, Philadelphia Veterans Adminis-tration Medical Center, Philadelphia, PA.

Objectives� Describe the concept of measurement invariance(MI) and its importance in interpreting and usingthe results of surveys.

� Discuss the MI for the mail and phone versions ofthe Bereaved Family Survey.

� Discuss implications of this research vis-s-vis otherpalliative care surveys.

Original Research Background. The VeteransHealth Administration (VHA) evaluates outcomes ofend-of-life (EOL) care using the Bereaved Family Sur-vey (BFS). Originally, the BFS was administered as atelephone survey, but it was transitioned to a mail sur-vey beginning October, 2012. The transition necessi-tated an evaluation of the tool’s validity using thisnew mode of administration.Objectives: The objective of this study was to validatethe mail version and to test for measurement invari-ance (MI) across the two administration modes.Methods. Telephone and mail versions of the BFSwere validated separately between October, 2009 andSeptember, 2013. MI was evaluated using a series ofconfirmatory factor analyses (CFA). Construct validitywas evaluated by calculating Cronbach Alpha coeffi-cients and examining differences between BFS Factorscores for groups with and without quality care indica-tors (e.g., receipt of a palliative care consult).Results. Our sample consisted of 35,682 decedentBFS scores (27,109 telephone surveys; 8573 mail sur-veys). BFS-item scores were slightly skewed, with a pre-dominance of higher scores for both the telephoneand mail version. The average missing rate for eachBFS item was minimal, just 2% for each version. TheCFA models demonstrated dimensional, configural,metric, and factor mean invariance across administra-tion modes. BFS factor scores were consistently higherwhen a patient received EOL quality care indicatorsregardless of mode of administration.Conclusions: These findings demonstrate the mea-surement invariance and robust psychometric proper-ties for the BFS across administration modes.Implications for Research, Policy orPractice. Accountability is an increasingly importantexpectation in palliative care, and measuring bereavedfamilies’ experiences of care through validated surveysis a common method for assessing outcomes. Ourfindings underscore the need to ensure that payers,


regulators, and healthcare systems establish thatdifferent modes of survey administration yield similarresults. Future research will need to examine the valid-ity and measurement invariance for web-basedbereaved family surveys.

Chronic Pain in the Ambulatory Palliative CareSetting: A Distinct Entity from Acute Pain?(S744)Jessica Merlin, MD, University of Alabama at Birming-ham, Birmingham, AL. Courtney Williams, MPH, Uni-versity of Alabama at Birmingham, Birmingham, AL.Malissa Pynes, BS, University of Alabama School ofMedicine, Birmingham, AL. Catherine McCarty, BSCandidate 2016, Healthcare Management & Psychol-ogy, University of Alabama at Birmingham, Birming-ham, AL. Elizabeth Kvale, MD, University ofAlabama at Birmingham Center for Palliative and Sup-portive Care, Birmingham, AL.

Objectives� Describe the prevalence of acute and chronicpain in an ambulatory palliative care setting.

� Describe the association between acute andchronic pain and outcomes in our ambulatorypalliative care setting.

Original Research Background. Acute pain is com-mon in ambulatory palliative care (APC), and includespain related to progression of serious illness and at theend of life. Chronic pain is pain lasting > 3 months,beyond the period of normal tissue healing. It has aunique pathophysiology, and I negatively impactshealth outcomes. Acute pain management typically in-volves opioids; treatment of chronic pain often limitsopioids and focuses on physical therapy, treatmentof comorbid mood disorders, and pain self-manage-ment/coping. Distinguishing these groups is impor-tant clinically.

Research Objectives. To characterize individualswith acute and chronic pain in APC.

Methods. Clinical surveillance data from 165 consec-utive consenting APC patients between 7/18/2012-5/22/2015 was examined. Chronic pain was defined asaverage pain on the Brief Pain Inventory (BPI) $ 4/10 at least twice > 3 months apart, acute pain asaverage pain $ 4/10 once, and depressive symptomsas PHQ-9 $ 10. Multiple regression was used to inves-tigate the cross-sectional relationship between paincategory and outcomes (BPI pain interference anddepressive symptoms).

Results. Among 165 participants, mean age was 52,and 75% were female. Mean number of visits was2.5. 35% had chronic pain, and 51% had acute pain.Compared to individuals with no pain and after adjust-ing for age and sex, pain interference was 0.55 pointshigher on average for individuals with acute pain on a

0 to 10 scale, and it was 1.0 points higher for individ-uals with chronic pain (p¼0.03 and 0.0003 respec-tively). Odds of depression were 3.7 times higher inacute pain and 4.0 times higher in chronic painthan in individuals without pain.Conclusion. Acute and chronic pain were commonand associated with worse outcomes; chronic painwas somewhat more strongly associated with higherlevels of pain interference and depression.Implications for Research, Policy orPractice. Additional research is needed to under-stand differences between acute and chronic pain inthis setting.

Teaching Pediatric Intensive Care PhysiciansCommunication Skills: The Enduring Effects(S745)Jennifer Walter, MD PhD MS, University of Pennsylva-nia, Philadelphia, PA. Parth Shah, BA, Candidateat the University of Pennsylvania, The Children’sHospital of Philadelphia (CHOP), Philadelphia, PA.Folasade Odeniyi, MPH, The Children’s Hospital ofPhiladelphia, Philadelphia, PA. Vanessa Madrigal,MD, Children’s National Medical Center, Bethesda,MD. Chris Feudtner, MD MPH PhD, The Children’sHospital of Philadelphia, Philadelphia, PA.

Objectives� Determine feasibility of a communication skillstraining (CST) to prepare pediatric intensivistsfor communicating bad news and assessing goalsof care in the pediatric intensive care unit(PICU).

� Describe the impact of CST on intensivist skill incommunication.

Original Research Background. Families of seri-ously ill children describe unmet needs for honest in-formation presented empathetically, while intensivistsreport inadequate training in having difficultconversations.Research Objectives. 1. To determine feasibility ofcommunication skills training (CST) to prepare pedi-atric intensivists for communicating bad news and as-sessing goals of care in the pediatric intensive careunit (PICU). 2. To describe the impact of CST on in-tensivist skill in communication.Methods. Intensivists volunteered to undergo CSTwith didactics, discussions with simulated parents,and a videotaped OSCE exam. Surveys prior to theintervention and one month after were tabulated fordescriptive statistics. Wilcoxon signed-rank testscompared outcomes at 2 time points. 2 independenttrained reviewers scored the OSCE using a validatedtool.Results. Twelve participants completed training. Inthe post-CST survey, all participants agreed the


training gave them skills to communicate in chal-lenging situations, and they would recommend it topeers. When comparing pre- and post-CST self-assess-ment measures of intensivists’ information-seekingfrom families, there was a significant increase 1 monthafter training (p¼0.03), with intensivists more likely toask what kinds of information families need and whattheir understanding of their child’s disease is, but nosignificant changes in information seeking or giving,which was not covered in the training. Finally, 11 ofthe 12 intensivists received passing scores on theOSCE as measured by a validated tool, with theaverage score being 48.5 (SD 5.92) compared to 38.6(SD 9.93) after training that was reported in theliterature.Conclusion. This study provides evidence that inten-sivists are willing to participate in CST and an OSCEexam, and they find it worthwhile. There is also evi-dence that they perceive an improvement in their skillset as a result of having participated.Implications for Research, Policy orPractice. Offering realistic, simulation-based CST isfeasible and effective for training intensivists.

Embedding Palliative Care into Bone MarrowTransplantation Clinic (S746)Danielle Noreika, MD, Virginia Commonwealth Uni-versity Medical Center, Richmond, VA. Egidio Del Fab-bro, MD, Virginia Commonwealth University,Richmond, VA. J. Brian Cassel, PhD, VirginiaCommonwealth University, Richmond, VA.

Objectives� Discuss the symptom burden present in a bonemarrow transplant clinic population.

� Describe the structure and benefit of palliativecare multidisciplinary intervention in a bonemarrow transplant patient population.

Original Research Background. Stem cell/bonemarrow transplantation (SC/BMT) is intensive ther-apy that creates the potential for a number of physicaland emotional symptoms; despite this there are nopublications describing palliative care involvement inthe course of treatment.Research Objectives. We studied the impact of palli-ative care interdisciplinary care on symptom manage-ment within a bone marrow transplant clinic.Methods. Retrospective chart review was performedon 37 patients followed over a 6-month period by apalliative care service embedded within the SC/BMTclinic.Results. 37 patients were referred by SC/BMT clinicphysicians or nurses to a palliative care teamembedded within the clinic (including a physician,physical therapist, and psychologist). Almost all pa-tients were referred for symptom management rather

than goals of care; only three (9%) died during the re-view period, and for none of them was the reason forconsultation goals-of-care/hospice referral. Most(77%) were allogenic transplant patients, and mostwere seen within 6 months of their transplantation.The most common reasons for referral were fatigue(57%), anorexia (27%), pain (38%), and depressionand/or anxiety (35%). At initial assessment, the high-est-rated symptoms were lack of appetite (mean 4.78,SD 3.08), fatigue (4.51 [2.59]), and diminishedfeeling of well-being (4.16, [2.51]). At initial assess-ment, 73% of patients had three or more differentsymptoms that they rated at 4+; this dropped to39.1% at follow-up (n¼23). Of the nine symptoms as-sessed at both initial and follow-up visits, sevendecreased significantly (all but fatigue and dyspnea)and none increased. For example, appetite improvedfrom 5.52 (2.98) to 3.13 (2.96) and pain improvedfrom 3.52 (2.92) to 1.78 (1.88) (n¼23, p<.01).Conclusion. Palliative care embedded within thebone marrow transplant clinic can provide benefit bylessening the symptomatic burden of patients.Implications for Research, Policy orPractice. Further study can help define patients in abone marrow transplantation setting who wouldbenefit from palliative care management.

Considering Care: A Descriptive Study of MoralDistress (S747)Elizabeth Smith, RN, Maimonides Medical Center,Brooklyn, NY. Toby Bressler, RN PhD(c) MPAOCN,Maimonides Medical Center, Brooklyn, NY.

Objectives� Understand the concept of moral distress inhealth care professionals and be able to identifytwo potential contributing factors and two poten-tial consequences of moral distress.

� Identify two strategies or types of interventionsthat a palliative care team and others can use ina hospital or other healthcare settings to mitigatemoral distress and improve staff morale.

Original Research Background. Moral distress in-volves stressful situations in which moral values arechallenged. As patient acuity rises, staff will likelyface more situations presenting ethical dilemmasthat may result in moral distress. Our academic medi-cal center serves a multicultural community that in-cludes a large population of a minority, faith-basedgroup, which influences decisions to utilize life-sus-taining therapy (LST). Patients on the respiratorycare unit (RCU) have a mean age of 82, have chronicventilator-dependent respiratory failure, and oftenutilize additional LST (tube feeding, dialysis, vasopres-sors). Faith-based minority patients are disproportion-ately high on this unit.


Research Objectives. To understand the experienceof moral distress and factors contributing to, and re-sulting from, that distress. The research explored cur-rent coping strategies and possible interventions toaddress identified issues.Methods. A descriptive, qualitative design was used,with convenience purposive sampling. IRB approvalwas obtained. All RCU nurses were invited to partici-pate. Participants provided demographic informationand took part in semi-structured focus groups. Tran-scriptions of audio recordings of the focus groupswere analyzed to identify themes.Results. Moral distress was evident in staff and mani-fested in many ways. Contributing factors includedcommunication issues, difficulty working with families,differences in values related to culture, and aggressive-ness of medical treatment. Consequences includedthemes of emotional and behavioral responses (deper-sonalization, desensitization, disempowerment). Demo-graphic differences between day and night staffsuggested different interventions needed. Staff offeredrecommendations, some of which have been imple-mented, and they demonstrate early positive impact onstaff engagement and morale. These include ethicsrounds, support sessions, and an ELNEC education day.Conclusion. Our findings indicate an urgent need torecognize and address moral distress in staff. Staffsatisfaction has important implications for optimalrelationship-based care as well as staff retention.Implications for Research, Policy orPractice. Further research evaluating interventionsare needed. Palliative care teams and bioethics consul-tation can be instrumental in providing staff educa-tion and support.

‘‘When I Heard Palliative Care, I HeardHospice’’: Parents’ Experiences WywithPediatric Palliative Care Consultation in theNeonatal Intensive Care Unit (S748)Erin Currie, PhD RN, University of Alabama at Bir-mingham School, Birmingham, AL. Marie Bakitas,DNSc CRNP AOCN ACHPN FAAN, University of Ala-bama at Birmingham, Birmingham, AL. Samuel Per-na, DO, University of Alabama at Birmingham,Birmingham, AL. Becky Christian, MSN RN PhDFNAP, University of Louisville, Louisville, KY. KarenMeneses, RN PhD FAAN, University of Alabama at Bir-mingham, Birmingham, AL.

Objectives� Describe the role of pediatric palliative careconsultation in the neonatal intensive care unit(NICU) setting.

� Describe parent experiences with a pediatric palli-ative care consultation in the NICU and implica-tions for practice and further research efforts.

Background. In 2013, 23,440 infants died in the US;most deaths occurred in the first 28 days of life. Pedi-atric palliative care consultation (PPC) in the neonatalintensive care unit (NICU) may provide much neededsupport for these infants and parents. Early in the crit-ical illness trajectory, PPC may assist with parental de-cision-making. However, there is a paucity of researchon parental perceptions of PPC and why these servicesmay be underused in the NICU until death isimminent.Research Objectives. To describe parents’ experi-ences with a PPC prior to their infant’s death in theNICU.Methods. In this descriptive qualitative study, we con-ducted individual audio-recorded, semi-structured in-terviews with a convenience sample of parents(N¼10) from a children’s hospital in the SoutheasternUS approximately four years after infant death. Uponreaching thematic saturation, verbatim transcribed in-terviews were verified for accuracy, coded, and contentanalyzed using qualitative descriptive methods. Weused member-checking to enhance trustworthinessof the findings.Results. Six of 10 parents had formal PPC. Most PPCoccurred near the end of life, and parents’ reported‘‘negative connotations’’ associated with the consultinitially, such as losing hope of curative treatment.However, all parents who received PPC would recom-mend this service to other parents and found PPC asa helpful layer of support. Specific positive experi-ences included: feeling like they had an extra advo-cate, a non-judgmental sounding board, and‘‘another support branch.’’Conclusions. PPC is often not considered until verynear death, and parents’ identified PPC as a markerof transition from curative to end-of-life care. Never-theless, parents found PPC to be valuable and wouldrecommend it to other parents.Implications for Research, Policy orPractice. Further research is necessary to understandthe factors that influence parental perceptions of PPCand how to identify opportunities for earlier PPC inte-gration in the NICU.

Hearing Loss in Hospice and Palliative Care: ANational Survey of Providers (S749)Alexander Smith, MD MPH MS, University of Califor-nia San Francisco, San Francisco, CA. Christine Ritch-ie, MD MSPH FAAHPM, University of California SanFrancisco, San Francisco, CA. Margaret Wallhagen,GNP PhD, University of California San Francisco,San Francisco, CA.

Objectives� Understand hospice and palliative medicine pro-vider perspectives on the impact of hearing loss


on communication in the older adult patientsthey care for.

� Understand that rates of formal training andknowledge about hearing loss management is low.

Original Research Background. Age-related hear-ing loss can impair patient-provider communicationabout symptom management, goals of care, and end-of-life decision making.Research Objectives. To determine whether hospiceand palliative care providers screen for or receivedtraining about hearing loss, believe it impacts patientcare, and use strategies to optimize communication.Methods. National survey of hospice andpalliative careproviders. Survey questions were pilot-tested with multi-disciplinary providers in San Francisco. We solicited re-sponses via emails to professional contacts and AAHPMmembers, the GeriPal blog, twitter, and Facebook. Re-sponses were collected using an online survey tool.Results. Of 510 responses (55% age 50+, 65% female,63% inpractice 5+ years, 55%practice primarily in inpa-tient/outpatient palliative care, 45% in hospice), 315were physicians, 50 nurses, 48 NPs, 58 social workers,and 39 chaplains. Ninety-one percent reported thathearing loss has some or great impact on the qualityof care for older adults. Eighty-eight percent recalleda specific instance of hearing loss impairing communi-cation with a patient, and 56% remembered it impair-ing communication with a caregiver. Eighty-sevenpercent of physicians, nurses, and NPs reported notscreening for hearing loss. While 62% felt comfortablewith their communication skills for patients with hear-ing loss, only 21% reported receiving formal trainingin its management, 31%were unfamiliar with resourcesfor patients with hearing loss, and 38%had never heardof a pocket talker amplification device.Conclusion. Hospice and palliative medicine pro-viders believe age-related hearing loss impacts care,yet most do not screen. While they feel they are manag-ingwell, fewhave formal training, and knowledge aboutmanagement approaches and resources is sub-optimal.Implications for Research, Policy or Practice. Thelack of research in this area is glaring relative to itsimportance. Universal screening should be consid-ered. Training in management strategies is needed.

Healing the Heart: Feasibility of a ‘‘High-Touch’’Model of a Community-Based Palliative CareProgram for Patients with Advanced HeartFailure (S750)Mona Patel, DO, Metropolitan Jewish Health SystemHospice and Palliative Medicine, New York, NY. LaraDhingra, PhD, Metropolitan Jewish Health SystemInstitute for Innovation in Palliative Care, New York,NY. Ann Wojtaszczyk, MD, Metropolitan Jewish HealthSystem, New York, NY. Jack Chen, MBS, Metropolitan

Jewish Health System Institute for Innovation in Palli-ative Care, New York, NY. Bernard Lee, MD, Metropol-itan Jewish Health System, Scarsdale, NY.

Objectives� Describe an innovative interdisciplinary, commu-nity-based palliative care program targeting heartfailure patients with high healthcare utilizationcosts.

� Discuss preliminary outcomes of a community-based palliative care team in securing advance di-rectives and hospitalizations/ED visits in a heartfailure cohort.

Original Research Background. Studies are neededto evaluate varied models of community-based pallia-tive care. Patients with advanced heart failure havehigh morbidity and healthcare utilization, and inter-disciplinary ‘‘high-touch’’ models may best addresstheir needs.Research Objectives. To evaluate feasibility of a‘‘high-touch’’ palliative care model for advanced heartfailure.Methods. We conducted a retrospective cohort anal-ysis of a pilot in which 20 patients (NYHA class III orIV, PPS score #70, $2 hospitalizations per 6 months)were offered at least-monthly visits by anMD/NP, socialworker visits, at least-weekly calls by an RN specialist,and access to 24-hour on-call. Patients incurred nocost andhad interventions that included symptomman-agement, advance care planning, weight monitoring,education about nutrition andmedication, andhospiceeligibility review. Data entered into an electronic medi-cal record were extracted for this analysis.Results. Of the 20 patients referred between June andDecember, 2014, six refused and 14 were enrolled.Mean age was 73.1 years (range 49-90), 85.7% wereNYHA Class III, and 85.7% had PPS scores of 60 or 70.During 6 months of care, patients averaged 3.6(SD¼1.4)MD/NP visits, 2.9 (SD¼1.6) social work visits,and 19.8 (SD¼9.9) RN calls. On-call contacts averaged1.4 (SD¼1.8). During treatment, mean hospitalizationswere 1.3 (SD¼1.5), ED visits were 0.4 (SD¼0.5), andonepatient elected hospice. All completed ahealthcareproxy; additional data regarding symptoms and satisfac-tion is being collected.Conclusion. Feasibility of this ‘‘high-touch’’ model ofcommunity-based palliative care in the populationwith advanced heart failure is supported by acceptanceof the program by almost three-quarters of thosereferred, no drop-outs after care started, and a veryhigh use of services.Implications for Research, Policy orPractice. Larger studies are needed to evaluate theclinical and economic outcomes produced by variedmodels of community-based palliative care in popula-tions with heart failure.


Association of Cancer-Related Fatigue with OtherSymptoms and Impact on Quality of Life ofPalliative Care Patients in a Tertiary CancerInstitute: A Prospective Observational Study(S751)Arunangshu Ghoshal, MD, Tata Memorial Centre,Mumbai, Maharashtra, India. Anuja Damani, MD,Tata Memorial Center, Mumbai, Maharashtra, India.Maryann Muckaden, MD MSc, Tata Memorial Hospi-tal, Mumbai, Maharashtra.

Objectives� Determine the correlation of factors associatedwith severity of fatigue and quality of life inadvanced cancer patients.

� Predictors of improvement in fatigue at firstfollow-up visit.

Original Research Background. Fatigue, along withother symptoms, affects quality of life (QOL) inadvanced cancer patients. The relative importance ofit is not known in the Indian population.Research Objectives. 1. To determine the correla-tion of factors associated with severity of fatigue inadvanced cancer patients. 2. To determine whetherthe severity of fatigue has any impact on the quality-of-life domain. 3. To determine predictors of improve-ment in fatigue at first follow-up visit.Methods. A prospective, observational study was con-ducted in the outpatient clinic from January to June,2014. Registered adult advanced cancer patientsmeeting the inclusion criteria ( ECOG /¼1) were as-sessed after taking informed consent for symptomburden (ESAS) and QOL (EORTC-QOL PAL15)along with demographic details. They were given stan-dard treatment for those symptoms. They met theteam or were telephonically contacted for the same af-ter an interval of 15 to 30 days. Descriptive statistics,comparison of baseline and follow up data, correla-tion and multiple linear regressions between fatigueand symptoms at baseline, logistic regression modelto determine factors associated with improvement infatigue were performed.Results. A total of 402 subjects were assessed at base-line and follow up (median age, 52 years; 51.6%male). Significant change in fatigue score wasobserved (p<0.001) at follow up. Hemoglobin, albu-min levels, type of cancer, sites of metastasis, ECOGscore, body weight, ESAS items except drowsiness,overall QOL, emotional functioning, and constipationwere found to be significantly associated with fatigueat baseline (p < 0.05). The logistic regression modelshowed that changes in hemoglobin and albuminlevels, pain, dyspnea, physical functioning, andinsomnia on QOL scale significantly contribute tothe improvement in fatigue.

Conclusion. Fatigue is strongly associated withcertain physical, emotional and biochemical parame-ters, some of which are predictive of improvement offatigue.

Implications for Research, Policy or Practice. It isa single-center study, so generalizability needs to be as-certained.

Implementing an Evidence-Based Tool forAssessing Pain in Non-Communicative PalliativeCare Patients: Challenges And Solutions (S752)Karen Kaiser, RN PhD AOCN, University of MarylandMedical Center, Baltimore, MD. Deborah McGuire,RN PhD, Virginia Commonwealth University, Rich-mond, VA. Carl Shanholtz, MD, University of Mary-land School of Medicine, Baltimore, MD. Mary EllenHaisfield-Wolfe, PhD, University of Maryland Balti-more, Baltimore, MD. Maura Deeley University ofMaryland, Baltimore, Baltimore, MD.

Objectives� Identify challenges and solutions to implementa-tion of a tool for assessing acute pain in non-communicative adult patients in a clinical setting.

� Evaluate MOPAT use over time.Original Research Background. Adult non-commu-nicative patients with acute pain are at high risk forunder-treatment due to inaccurate assessment. Consis-tent use of a reliable, valid, clinically useful pain assess-ment tool improves assessment, but there is littleinformation about facilitating clinical implementationof evidence-based tools in this population.

Research Objectives. Identify challenges and solu-tions to implementation of a tool for assessing acutepain in non-communicative adult patients in a clinicalsetting. Evaluate Multidimensional Objective PainAssessment Tool (MOPAT) use over time.

Methods. At a hospital in which most nursing docu-mentation was performed on paper, the MOPAT wasbuilt into the electronic health record (EHR) to facil-itate data retrieval for a funded study. Leadershipselected unit-based nurse champions to facilitate im-plementation. Data abstracted from the EHR wereused to develop weekly compliance audits and wereshared with the champions, along with e-mails thatincluded screen shots and documentation require-ments. MOPAT compliance fluctuated and was insuffi-cient, so nurse champions suggested daily feedbackand bedside documentation reminders. Some unitsused additional strategies, such as bedsidedemonstrations.

Results. The unit that used bedside demonstrationswas the first high-accruing unit to reach the 90%compliance target. Across all participating units,


weekly compliance fluctuated between 79% and 92%for the first 11 weeks, with only 3 intermittentlydispersed weeks at or above 90%. Individual daily feed-back resulted in an 89 to 97% completion rate sus-tained for at least 7 weeks.Conclusion. Multimodal strategies were needed tointegrate an evidence-based pain tool for adult non-communicative patients into practice. Utilizing unit-based champions was an important strategy thatfacilitated implementation, including recommendingstrategies to boost compliance and usage.Implications for Research, Policy orPractice. Unit-based champions and feedback areimportant strategies for clinical implementation of ev-idence-based pain tools in patients who cannot self-report.Supported by NINR 5R013664.

Implementing Primary Palliative CareIntervention in Transitional Care Practice:Feasibility, Barriers, and Facilitators (S753)Seiko Izumi, RN PhD, Oregon Health and ScienceUniversity, Portland, OR. Basilia Basin, BS, OregonHealth and Science University, Portland, OR. MargotPresley, BA MN, Oregon Health and Science Univer-sity, Portland, OR. Jean McCalmont, RN, OregonHealth and Science University, Portland, OR. JudithBaggs, RN PhD FAAN, Oregon Health and ScienceUniversity School of Nursing, Portland, OR.

Objectives� Describe feasibility, barriers, and facilitators toimplement a new intervention into practice.

� Discuss strategies to close the research-practicegap in context of palliative care intervention.

Original Research Background. While develop-ment of effective interventions to improve care qualityand health outcomes is an urgent healthcare issue,gaps exist between potentially effective interventionand its implementation in practice. Careful examina-tion of feasibility and identification of variables thatfacilitate or hinder implementation is a key to closethe gap.Research Objectives. We conducted a formativeevaluation study to assess feasibility and implementa-tion barriers and facilitators of a newly developedintervention integrating primary palliative care intransitional care for older adults with chronicconditions.Methods. The Transitional Palliative Care (TPC)intervention involved a home visit by a nurse andhealth coach and 3 months of telephone follow-upfocusing on symptom management and advance careplanning. We enrolled 20 older adults dischargedfrom hospital to home in the intervention group toassess intervention feasibility. At the end of the

intervention, all participating patients, two interven-tion nurses and seven health coaches were inter-viewed. Data were analyzed using qualitative contentanalysis.Results. Four participants withdrew because theyperceived the intervention was either burdensome(n¼2) or not needed (n¼2). Another participanthad a hospital readmission during study period anddid not complete the study. Patients who completedthe study found the intervention helpful. However,the components of care perceived as most or leasthelpful varied among participants. Interventionistssaid the major challenge was complexity and diversityof patient needs. To respond to the complex anddiverse needs, being flexible and resourceful, havinggood communication skills to work with various teammembers, and having clinician champions who advo-cate for the TPC nurse facilitated the intervention.Conclusion. To be successful implementing an inter-vention in practice, the intervention and intervention-ists need to be well situated in the practice, knowingresources and collaborators and having support fromchampions.Implications for Research, Policy or Practice. It iscritical to tailor the intervention fit to the setting whileidentifying the essential components of the interven-tion that are generalizable to other settings.

A Review of Claims-Based Quality Measures Usedby the Centers for Medicare and MedicaidServices (CMS) and Medicare AdministrativeContractors (MACs) to Monitor the MedicareHospice Benefit (S754)Michael Plotzke, PhD, Abt Associates, Cambridge, MA.Thomas Christian, PhD, Abt Associates, Cambridge,MA. Joan Teno, MD MS, University of Washington, Se-attle, WA. Pedro Gozalo, PhD, Brown University, Prov-idence, RI.

Objectives� Describe measures that CMS and MACs use tomonitor hospices participating in the MedicareHospice Benefit.

� Compare characteristics of hospices that are out-liers along the five measures to the overall charac-teristics of all hospices that participate in theMedicare Hospice Benefit.

Original Research Background. As part of theMedicare Hospice Benefit (MHB), hospices submitclaims containing information that allows policymakers to identify outcomes with large variation acrosshospices. Identifying outliers that have poor outcomescan help policy makers improve the MHB and in-crease the quality of care being provided.Research Objectives. Identify hospices that are out-liers in the provision of hospice services along five


different quality measures: (1) rate of not providingskilled visits at the end of life (2) average length ofstay (ALOS), (3) live discharge rates, (4) general inpa-tient (GIP) care days, and (5) nursing minutes pro-vided per day.

Methods. Quality measures are calculated using100% of Medicare hospice claims from January 1,2010 through January 31, 2013. For each measure,hospices are grouped into deciles. An overall countof how many times a hospice appears in the eighthdecile or higher is made to determine which hospicesare outliers.

Results. There are 14 hospices that are in the highestthree deciles for the first three measures and thelowest three deciles for the last two measures. 226 hos-pices are in the worst three deciles for at least fourmeasures. The majority of those hospices (70.8%)are located in the south census region, and 80.4%are for-profit providers. The average spending perbeneficiary for those hospices is $25,518, comparedto $14,977 per beneficiary for all hospices.

Conclusion. Using this data, CMS and MACs canidentify hospices that are outliers for a given measure.Not all outliers indicate a serious problem, however ifa hospice is an outlier for several measures, it mayindicate questionable practices and a need for closerinspection by CMS and MAC.

Implications for Research, Policy orPractice. Hospices should monitor their outcomesalong the measures discussed to understand howthey perform compared to their peers.

Surgery Without a Surrogate: The LowPrevalence of Healthcare Power of AttorneyDocuments Among Pre-Operative PatientsRequiring General Anesthesia (S755)John Wanner Medical Student, Medical College ofWisconsin, Milwaukee, WI. Sean Marks, MD, MedicalCollege of Wisconsin, Milwaukee, WI. George LangeRiver Hills, WI.

Objectives� Establish the importance of identifying a health-care power of attorney (HCPOA) agent prior tosurgery requiring general anesthesia.

� Quantify the prevalence of HCPOA documentsimplemented into the EMR prior to surgeryrequiring general anesthesia.

Original Research Background. Surgery requiringgeneral anesthesia is associated with significantmorbidity and mortality. This often creates pre-opera-tive psychological distress for patients and families.While there has been considerable research and effortto improve risk stratification of medical conditionsprior to surgery, there has been little research andfew documented quality improvement efforts

regarding the appropriate implementation of HealthCare Power of Attorney (HCPOA) documents intothe electronic medical record (EMR) prior to surgery,even though studies have shown a correlation betweenan advanced care planning and patient autonomy andquality of life.

Research Objectives. (a) Investigate the prevalenceof HCPOA documents incorporated into the EMR ofpatients undergoing elective surgery and requiringgeneral anesthesia at four different health care institu-tions with well-established palliative care and advancecare planning programs. (b) Investigate correlationsbetween HCPOA documents and age, sex, marital sta-tus, American Society of Anesthesiologists Physical Sta-tus classification system (ASA), insurance coverage,body mass index, and zip code of patient’s residence.

Methods. We performed a retrospective chart reviewof the first 500 consecutive adult patients (18 yearsor older) undergoing elective surgery that requiredgeneral anesthesia between the dates of January 1,2012 to December 31, 2012 at one of four medical cen-ters with well-established EMR systems as well asregional reputations for advance care planning andpalliative care. We excluded patients undergoingemergent surgeries and a court appointed guardian.Patient information was de-identified after demo-graphic information and HCPOA information werecollected. A descriptive analysis and logistic regressionanalysis were performed to examine associations.

Results. Of 1723 charts reviewed, only 382 had aHCPOA document implemented into the EMR atthe time of surgery requiring general anesthesia.Twelve of the subjects reviewed were physicians, andonly three of the physicians had a HCPOA imple-mented into the EMR at the time of surgery. Theodds of having HCPOA implemented into the EMRwere significantly higher with age, female gender,and higher ASA scores. There was no evidence thatbody mass index, insurance type, and socioeconomicstatus based on zip code group correlated with therate of HCPOA documents. There was significant vari-ability between healthcare institutions, and the oddsof having a HCPOA implemented in the EMR weresignificantly lower for widows.

Conclusion. Less than a quarter of patients undergo-ing a surgery requiring general anesthesia have aHCPOA document implemented into the EMRdespite the known associated morbidity and mortalityrisks. The presence of EMR systems, well establishedpalliative care programs, and advance care planningadvocacy taskforces appear to be insufficient to ensurethat clinicians have appropriate documentation of asurrogate prior to a planned surgery.

Implications for Research, Policy orPractice. Further research and quality improvement


initiatives are needed to identify how HCPOAs can bebetter identified prior to surgeries and medical inter-ventions. The low prevalence identified in this studyrepresents a significant patient safety concern.

Milestones for the Final Mile: InterspecialtyDistinctions in Primary Palliative Care SkillsTraining (S756)Chithra Perumalswami, MD, University of Michigan,Ann Arbor, MI. John Harris, MD, University of Michi-gan, Ann Arbor, MI. Lindsey Herrel, MD MS, Univer-sity of Michigan, Ann Arbor, MI. Mark Healy, MD,Center for Healthcare Outcomes & Policy, Ann Arbor,MI. Lauren Wancata, MD, University of Michigan, AnnArbor, MI.

Objectives� Articulate the importance of primary palliativecare skills for all residents in training.

� Identify examples of directly salient and indirectlysalient milestones within different specialty mile-stone documents.

� Apply knowledge gained from this research tohospice and palliative medicine policy changesat local and national levels.

Original Research Background. Many physiciansdo not receive training in primary palliative care skills(PPCS). The Accreditation Council for Graduate Med-ical Education (ACGME) and specialty boards recentlycreated milestone documents to improve the qualityof graduate medical education. It is unclear to whatextent these residency evaluation milestones consis-tently address PPCS.Research Objectives. To characterize the variationand quality of PPCS in residency outcomes-basedmilestones.Methods. We performed a content analysis with struc-tured implicit review of 2015 ACGME milestone docu-ments from fourteen medical and surgical specialties.For each milestone document, we identified the totalcount of milestones directly and indirectly salient toPPCS, the total count of pain management-relevantmilestones, the frequency of milestones by ACGMEcore competencies, and the average developmentalprogression level of salient milestones in each spe-cialty milestone document.Results. 959 occurrences of 29 palliative search termswere identified. Implicit review characterized 104milestones with direct saliency to PPCS and 196 mile-stones with indirect saliency. Inter-rater agreement ofthe saliency rating was 89%. Palliative care milestoneswere most commonly found in milestone documentsfor Anesthesiology, Pediatrics, Urology, and PhysicalMedicine and Rehabilitation. PPCS-relevant mile-stones were most commonly found in the

Interpersonal and Communication Skills core compe-tency, with 108 (36%) relevant milestones identified.Conclusion. Future revisions of specialty-specificmilestone documents should focus on currently un-der-represented, but important PPCS.Implications for Research, Policy or Practice. ThePalliative Care and Hospice Education and TrainingAct was recently re-introduced before Congress. It pro-poses to commit significant federal resources toimprove palliative care education. With an aging pop-ulation and anticipated shortage of physicians withformal palliative care training, knowledge of PPCSamong all physicians will become increasingly impor-tant. Systematic incorporation of PPCS into the mile-stone documents is one potential step towardsensuring current residents receive basic training insymptom management and communication skills.

Carrot or Stick? Mandatory Versus OptionalFields for Capturing Palliative Care QualityMetrics in an Electronic Medical Record (S757)Zachary Binney, MPH, Emory University - RollinsSchool of Public Health, Atlanta, GA. Michael O’Neill,MD FACP, Emory University School of Medicine, At-lanta, GA.

Objectives� Describe a method of documenting JCAHO palli-ative care quality metrics in an electronic medicalrecord.

� Evaluate the potential impact of making palliativecare quality metric documentation fields requiredversus optional in an electronic clinical note.

Original Research Background. To improve docu-mentation of quality metrics, a multidisciplinaryteam of clinicians designed new documentation tem-plates to capture information on dyspnea, nausea,bowel regimens when opioids prescribed, identity ofthe legal decision maker, and initiation of spiritualsupport.Research Objectives. To determine what proportionof initial inpatient palliative care (PC) consultsincluded quality metric data when the note fieldswere mandatory versus optional in three southeasternacademic hospitals.Methods. We compared the documentation percent-ages from January to April (mandatory fields) withJune and July 2015 (optional fields). Dyspnea andnausea screens were a ‘‘Yes/No/Unable to assess’’question. The note asked whether opioids were initi-ated or continued (yes or no) and about relevantbowel regimens. Name and phone number of thelegal surrogate decision maker were entered in freetext fields. Spiritual support offerings were recordedas ‘‘Yes/Declined/Deferred.’’


Results. There were 1428 initial consults and 2636follow-up visits during the ‘‘mandatory period’’ and576 and 1340 during the ‘‘optional period.’’ Docu-mentation rates were 100% when mandatory. Duringthe optional period, the documentation rates were:dyspnea screen, 82%; nausea screen, 73%; offers ofspiritual support, 80%; and surrogate name andphone documentation 89% and 80%, respectively.Opioid use was documented in 59% of initial con-sults when optional; clinicians reported positiveopioid use in 45% of consults when mandatory butonly 29% when optional. Dyspnea and nausea were‘‘unable to be assessed’’ in w30% of mandatoryversus w20% of optional consults. 5% of mandatoryphone numbers were invalid entries just done tocomplete the note.

Conclusion. Although the note was built with multi-disciplinary clinician input to optimize workflow,some objected to the additional mandatory fields.Making these optional reduced documentation byw10-30%.

Implications for Research, Policy orPractice. Though potentially cumbersome, makingquality data fields optional results in a substantialdrop in the amount of quality data recorded.

Artists’ Perspectives on Encounters with PalliativeInpatients, a Qualitative Study (S758)Katherine O’Brien, MD, MedStar Georgetown Univer-sity Hospital, Washington, DC. Julia Langley, MA,Georgetown University Hospital, Washington, DC.Kristi Graves, PhD, Georgetown University, Washing-ton, DC. Kathleen Anderson, MD MS, GeorgetownUniversity Hospital, Washington, DC.

Objectives� Discuss non-pharmacological, multidisciplinaryinterventions appropriate for palliative medicinepatients.

� Learn overarching themes discovered throughartists’ reflections.

Background. In January, 2015, our Palliative Medi-cine Program teamed up with our cancer center’sArts and Humanities Program to send artists toperform for palliative inpatients at bedside. Currentliterature supports the positive impact of music andart on patients with chronic illnesses. However, theencounter between artist and patient is not just one--directional; it is a rich interaction where both indi-viduals are affected. After each encounter with ourpalliative patients, artists wrote down their thoughtsto encourage self-reflection and self-care. This qual-itative study examined artists’ reflections and un-covered common themes of these therapeuticinteractions.

Research Objectives. To identify overarchingthemes/outcomes/impacts of the Arts and Human-ities program at Georgetown University on artistsand patients from the palliative medicine service.

Methods. We performed a retrospective record re-view of artists’ reflections on their patient interactions.We conducted a qualitative review of 50 existing jour-nal entries. Two reviewers initially analyzed seven en-tries and extracted pertinent themes. Reviewersdiscussed and revised themes. Reviewers examined re-flections from practitioners across multiple disci-plines, including a cellist, a singer, a violinist, aharpist, a fabric artist, an expressive writer, and adancer.

Results. Initial themes that emerged includedimpact of the arts and humanities program on pa-tients’ physical well-being, emotional well-beingand social well-being; impact on the artists’included elements of emotional and social well-be-ing. Physical well-being was documented as artists’reported observations of both non-verbal and verbalpatients. Among non-verbal patients, artist’ re-ported that the arts activity appeared to trigger pa-tients’ relaxation of the facial muscles, smiling andhumming. Among verbal patients, artists reportedpatients’ emotional well-being improved by notingan increased sense of peace and strength. Further,among verbal-patients, social well-being changeswere noted as both inter-personal and intra-familial level of engagement. Specifically, interper-sonal connections were observed among patientswho sought connection with the artists by inquiringabout the artists’ craft/trade and personal stories.Intra-familial engagement was also reported amongyounger patients who were observed to engage inarts activities with their parents and other familymembers.

Conclusion. Through the course of our analysis ofthese reflections, it is clear that our program hashad a meaningful impact not only for our patients,but has also had a true influence on the artists.

Implications for Research, Policy orPractice. This study has wide application in furtherresearch and practice. Firstly, this qualitative studylends itself to a quantitative symptom assessmentwith respect to the Arts and Humanities program.Further research could be done looking at pre- andpost-interactions on symptoms as well. Finally, thisstudy provides observations to the palliative medicinecommunity about the impact of this program on pa-tient’s physical, emotional and social well-being, aswell as the artist’s, which is an interesting addition tothe literature on humanities-based interventions inpalliative medicine.


Decision Making Process of Parents withSeriously Ill Children at the Hospital (S759)Maira Misko, RN MSN PhD, Federal University of S~aoPaulo, S~ao Paulo, Brazil. Regina Bousso, RN MSc PhD,Federal University of S~ao Paulo, S~ao Paulo, Brazil.Maiara Rodrigues Santos, RN MSN, Federal Universityof S~ao Paulo, S~ao Paulo, Brazil.

Objectives� Identify the core category for parents of a seri-ously ill child about the decision making processat the hospital.

� Identify parents’ preferences when they have tomake a decision on behalf of their seriously illchild.

Original Research Background. Changes related tothe decision making of parents of seriously ill childrenat the hospital have been reported in the literature,emphasizing the active role of parents and profes-sionals in sharing information. Professionals are un-prepared to deal with the dying process, andparental involvement in decisions is important forthe care and future of the family.Research Objectives. This study aimed to under-stand the experience of parents of seriously ill chil-dren regarding the decision-making process in thehospital.Methods. This is a qualitative study using SymbolicInteractionism and Grounded Theory as theoreticaland methodological framework. Data collection wasperformed in a pediatric hospital in S~ao Paulo,through active observation, hospital records andsemi-structured interviews with 10 parents who hadtheir children hospitalized with a life-threatening con-dition during the data collection period. The inter-views were recorded and transcribed. Data wasanalyzed following the procedures of the GroundedTheory.Results. After the theoretical saturation had beenreached, it was possible to propose a theoretical modelto explain the decision-making process of parents bythe core category: Being good for my child is beinggood to me, and the following categories: being scary,recognizing that everything is being done for thechild, needing information, deciding about the partic-ipation in decision-making, having faith and hope,and valuing a relationship of trust with healthproviders.Conclusion. The results indicate that parents’ experi-ence in decision-making is related to individual prefer-ences and the relationship with the healthcare team,which allow them to trust some decisions to physiciansand to play an active role as their children’s sadvocates.Implications for Research, Policy orPractice. Ensuring family care, from what parents

consider good for their child, allows nurses to guar-antee the active role of parents in the decision-makingprocess.

Challenges of Providing End-of-Life Care forHomeless Veterans (S760)Evelyn Hutt, MD, Eastern Colorado Veterans Adminis-tration Health Care System, Denver, CO. JacquelineJones, RN PhD FAAN, University of Colorado, Aurora,CO. Karen Albright, PhD, University of Colorado, An-schutz Medical Campus, Denver, CO. Mary Weber,PhD PMHNP-BC FAANP, University of Colorado,Aurora, CO. Thomas O’Toole, MD, Providence Veter-ans Administration Medical Center, Providence, RI.

Objectives� Explain quantitative and qualitative aspects of thechallenge of caring for homeless Veterans whoare approaching the end of their life.

� Describe the challenges that are frequentlyencountered in caring for homeless Veteranswho are approaching the end of their life.

� Discuss and categorize potential solutions to thechallenges of care for homeless Veterans at theend of their life.

Original Research Background. More than 76,000Veterans are estimated to be homeless on any night.Among the homeless, mean age at death is 34-47 years.Veterans who are both homeless and at the end of life(EOL) do not fit readily into programs for homelessVeterans (HV) or those at end of life.Research Objectives. (1) Describe current servicesand perceived challenges of caring for HV at EOL bysurveying existing Veterans Administration (VA),homeless Veterans, and end-of-life programs. (2)Develop a deep and broad understanding of the is-sues, barriers and facilitators to excellent EOL carefor HV. (3) Define the key structural, clinical and pol-icy elements required to deliver excellent care to HVat EOL.Methods. Using a mixed-methods sequential design,VA homeless and EOL programs were surveyed. Keyinformant interviews and focus groups with HV, multi-disciplinary providers, and community and VA leader-ship were conducted at four geographically dispersedVA facilities. A National Program and Policy Develop-ment Forum is addressing the challenges uncovered.Results. Interviewees and focus group participantsemphasized: (1) While declining health of HV pre-vents independent living or realistic plans to abstain,housing options are too often limited to places thatinsist on functional independence and sobriety. (2)Pain management within the context of addiction, un-stable housing, and behavioral health problems arechallenging. (3) Discontinuities within and betweensystems restricts care delivery. (4) VA regulations


pose significant challenges to collaboration with com-munity providers. (5) Care providers for HV at EOLmust compete for attention and resources with otherpressing challenges within VA.

Conclusion. Lack of housing suited to HV withrapidly declining health and isolation of homelessand EOL providers from each other are among themost pressing challenges.

Implications for Research, Policy or Practice. TheForum is developing proposals to facilitate alreadyfunctioning, informal collaborations among HV andEOL care providers, maximize VA-community partner-ships, and expand peer support services by formerlyhomeless Veterans.

Feasibility of Outpatient Advance Care PlanningDiscussions: Adventures of a Primary CarePhysician (S761)Molly Collins, MD, Massachusetts General Hospital,Boston, MA. Daniel Horton, MD MSCE, RutgersBiomedical and Health Sciences, New Brunswick, NJ.Brooke Worster, MD, Jefferson University Hospital,Philadelphia, PA.

Objectives� List at least three patient factors associated withan increased likelihood of having advance careplanning discussions.

� State one new way that advance care planningmay be integrated into routine primary care.

Original Research Background. Although primarycare providers are well poised to initiate and conductadvance care planning discussions (ACP), we know lit-tle about the feasibility of integrating ACP into routineprimary care outside of QI settings.

Research Objectives. We aimed to determine thescope of and factors related to ACP for one primarycare provider’s patients.

Methods. We performed a chart review of all patientson a primary care provider’s panel (MEC) between2012 and 2015. We evaluated clinical and systems fac-tors associated with ACP using multivariable logisticregression.

Results. Among 1074 patients on the panel, 68 (6%)had documented ACP. Those with ACP included 41%of patients $65, 60% of patients whose deaths wouldhave been unsurprising in the next year, and six ofseven patients who died. During sessions when ACPtook place, there was no difference in clinic patientvolume compared to the provider’s average in thesame year. Although 25% of those with ACP had estab-lished written wishes, few (n¼3) subsequently broughtin advance directives; few others (n¼3) completednew advance directives. Healthcare representatives(named in 84% of ACP) were also commonly thenext of kin (79%) or listed emergency contact

(83%). Factors independently associated with ACPwere older age, number of clinic visits, active cancerdiagnosis, and patients whose death would be unsur-prising. Interestingly, among patients $65 withoutserious illness, each additional non-life-threateningcomorbidity reduced the likelihood of ACP by 44%.

Conclusion. Targeting ACP to older and seriously illpatients is feasible in a busy primary care practice.Medical complexity may be a deterrent to havingACP with patients without life-threatening illness.

Implications for Research, Policy or Practice. Weshould prioritize conversations in ACP rather thancompletion of advance directives. Listed emergencycontacts could provide a gateway for establishinghealthcare representatives. New proposed paymentmodels may help facilitate additional discussions forall patients.

A Survey and Qualitative Interview of ParisianPalliative Care Professionals’ Views of End ofLife, Death, and Dying (S762)Viktoriya Tulchinskaya, BA, Kansas City, KS. Deon Hay-ley, DO, University of Kansas, Kansas City, MO.

Objectives� Compare the organization of the palliative caresystems in France and the United States.

� Articulate the purpose and significance of theTempler Death Anxiety Scale.

� Interpret the difference between a score of 0 anda score of 15 on the Templer Death Anxiety Scale.

Original Research Background. Among the 191countries whose healthcare systems were evaluatedby the WHO in 2000, France ranked first overall.Also, as the first country to start hospice, France hasbeen instrumental in the promotion and spread ofhospice and palliative care (PC). The current re-searchers wished to explore French PC professionals’views on end of life; it is hypothesized that these viewsmay be influenced by and in turn influence patient-provider interaction.

Research Objectives. How do PC professionals’ ex-periences in PC influence their perceptions of endof life?

Methods. PC professionals from two PC organiza-tions in Paris, France were invited to participate. Par-ticipants completed demographics information, theTempler Death Anxiety Scale (DAS), and a semi-struc-tured interview regarding experiences in PC, their pa-tients’ experiences, and personal views about end oflife. Demographics and DAS scores were compared us-ing a t-test. Common themes were extracted from theinterviews. The IRB at the University of Kansas Medi-cal Center approved this study.

Results. 29 PC professionals were interviewed (27 fe-males, 2 males). No statistically significant differences


in DAS scores were found in comparisons across age,gender, religion, religiosity, and number of PC pa-tients cared for in the last 2 years. Formal training inPC was the variable closest to statistical significance(P ¼ 0.12); this may be clinically significant. Severalcommon themes arose from analysis of interviews:fear of something other than death, desire for eutha-nasia, holistic patient care, improvement of qualityand quantity of life for PC patients, impact on pa-tients’ families, and a reorganization of PC providers’life priorities.Conclusion. Formal training in PC may substantiallydecrease providers’ fear of death, while notablyimproving quality of life for patients and theirfamilies. France may be a model to the world of a suc-cessful national system of PC and a holistic patient-centered approach to PC.Implications for Research, Policy or Practice. Itencourages additional training in PC to healthcareprofessionals.

Antithrombotic Therapy upon Discharge toHospice Care (S763)Jon Furuno, PhD, Oregon Health & Science Univer-sity College of Pharmacy, Portland, OR. Brie Noble,BS, Oregon State University College of Pharmacy,Portland, OR. Christina Kowalewska, PharmD, Ore-gon Health & Science University, Portland, OR. MaryLynn McPherson, PharmD BCPS CPE, University ofMaryland School of Pharmacy, Annapolis, MD. ErikFromme, MD MSCR FAAHPM, Oregon Health & Sci-ence University, Portland, OR.

Objectives� Describe the prevalence of antithrombotic ther-apy upon discharge from acute care to hospicecare.

� Describe the most frequent antithromboticagents prescribed upon discharge to hospice.

� Identify patient and disease characteristics associ-ated with receiving a prescription for antithrom-botic therapy upon discharge to hospice.

Original Research Background. Patients transition-ing to hospice care face difficult decisions regardingcontinuation of chronic medications.Research Objectives. Wequantifiedthefrequencyandcharacteristicsofpatientsreceivingantithromboticther-apyupondischargefromacutecaretohospicecare.Methods. This was a retrospective cohort study ofadult ($21 years) patients discharged directly fromOregon Health & Science University to hospice carebetween 1/1/2010 and 6/30/2014. The primaryoutcome of interest was receiving an outpatient pre-scription for anticoagulation or antiplatelet therapyupon discharge to hospice care. Data were collectedfrom an electronic repository of medical record data

and through review of physician notes and hospitaldischarge summaries.Results. Among 1141 eligible patients, 77 (6.8%) pa-tients received a prescription for antithrombotic ther-apy upon discharge to hospice care. Aspirin (57.1%),enoxaparin (24.7%), and warfarin (20.8%) were themost frequently prescribed antithrombotic agents.Multivariable logistic regression analysis suggestedthat patients treated for a deep venous thromboembo-lism or pulmonary embolism on the index admissionor with a history of atrial fibrillation or aortic/mitralvalve replacement were significantly more likely toreceive antithrombotic therapy upon discharge(p<0.05 for all). In contrast, patients with a historyof cancer, cerebrovascular disease, or liver diseasewere significantly less likely to receive antithrombotictherapy (p<0.05 for all). Among the 77 patients whoreceived a prescription for antithrombotic therapyupon discharge, 22% were not previously receiving an-tithrombotic therapy prior to the index admission.Among patients previously receiving antithrombotictherapy, more than half (55%) did not have anycharted rationale for continuation.Conclusion. Antithrombotic therapy upon dischargeto hospice was associated with active treatment and co-morbid conditions rather than terminal diagnoses.Decisions to continue antithrombotic therapy oftenlacked rationale in patients’ medical records.Implications for Research, Policy orPractice. Further research is needed on the safetyand effectiveness of antithrombotic therapy in hospicecare and current drivers of medication decisions inthe absence of these data.

Facilitators of and Barriers to InterdisciplinaryCommunication and Collaboration in PalliativeCare and Primary Care (S764)Nancy Dudley, RN MSN MA, University of California,San Francisco, San Francisco, CA. Margaret Wallha-gen, GNP PhD, University of California, San Francis-co, San Francisco, CA. Christine Ritchie, MD MSPHFAAHPM, University of California, San Francisco,San Francisco, CA. Roberta Rehm, RN PhD FAAN,University of California, San Francisco, San Francisco,CA.

Objectives� Describe the facilitators of interdisciplinarycollaboration to coordinate care for older adultsliving longer with serious illnesses.

� Identify and describe the barriers to interdisci-plinary collaboration to coordinate care for olderadults living longer with serious illnesses.

� Describe strategies to promote interdisciplinarycommunication and collaboration and awarenessof primary and secondary palliative care.


Introduction. As a component of advanced illnessmanagement, palliative care in the outpatientsetting can address the complex care needs of olderadults living longer with serious illnesses. Communi-cation and collaboration between primary care andpalliative care providers is needed to deliver com-plex care management and to coordinate care, yetoptimal strategies for collaboration are ill defined.This exploratory study revealed insights into thestudy question: What are the facilitators of and bar-riers to interdisciplinary interactions to coordinatecare?

Methods. Participants were selected through snow-ball sampling from large academic and communityhealthcare systems with established community-based palliative care services. Twenty semi-structuredinterviews were conducted, including primary careand palliative care providers and their patients andfamilies. Interviews were audio recorded and tran-scribed verbatim. Participants completed a brief sur-vey regarding their background, education andexperience with palliative care. Transcripts and fieldnotes were analyzed using Grounded Theorytechniques.

Results. Four major themes emerged from the data:(i) role clarity, (ii) feedback and collaboration, (iii)workforce need, and (iv) education. Interdisci-plinary collaboration to coordinate care was facili-tated by defining roles and responsibilities;frequent in person, email, or EMR communication;and education of primary care providers and pa-tients and families regarding primary and secondarypalliative care. Barriers that negatively impactedworking relationships among primary care and palli-ative care providers included poor feedback that pre-vented a shared understanding of patient’s needsand goals of care. Other contributing factors werenon-involvement of primary care providers whenspecialists referred patients to palliative care, lackof resources, and an unclear concept of commu-nity-based palliative care.

Conclusions/Policy. Data suggest the need forgreater attention to processes that promote communi-cation and collaboration as well as strategies to pro-mote a greater awareness of primary and secondarypalliative care.

Pilot Study of Subjective Taste and Smell Changesin Treatment-Naive Patients with Solid Tumors(S765)Lorrane Spotten, BSc, Dublin Institute of Technology,Dublin, Ireland,. Declan Walsh, MD, Trinity CollegeDublin, University College Dublin, Our Lady’s Hos-pice and Care Services, Dublin, Ireland. Cliona Lor-ton, MB, Our Lady’s Hospice and Care Services,

Dublin, Ireland. Clare Corish, PhD, Dublin Instituteof Technology, Dublin, Ireland.

Objectives� Describe the prevalence, severity and characteris-tics of taste and smell changes in treatment-naivepatients with solid tumors.

� Examine the association between taste and smellchanges, malnutrition risk and other symptomsin cancer.

Background and Aims. Taste and smell changes(TSCs) have been mostly studied in cancer post-chemotherapy (CT) or radiotherapy (RT) and inhead and neck (H&N) tumors. They may present aspart of a symptom cluster along with anorexia, earlysatiety and weight loss, which can negatively impactnutritional status. The aims of this study were toexamine the prevalence, severity and characteristicsof TSCs and their relationship with co-occurring symp-toms in non-H&N solid tumors before CT or RT.

Methods. A prospective observational study was con-ducted. Forty consecutive pre-treatment cancer refer-rals who attended radiation oncology outpatientsover a six-week period were recruited. Data on TSCs,symptoms, dietary intake and nutritional status wereobtained by the Taste and Smell Survey and theabridged Patient-Generated Subjective Global Assess-ment (abPG-SGA). Weight and height were measured,and BMI was calculated. SPSS� was used for statisticalanalysis. Two-sided P values <0.05 were statisticallysignificant.

Results. Most were newly diagnosed (70%; n¼28).Nineteen (48%) reported TSCs. Nine noted strongersweet taste, and seven noted stronger salt taste. Ofthose, four reported stronger and four weaker odorsensation. Those deemed at nutritional risk by theabPG-SGA had more TSCs (P¼0.057). TSCs weresignificantly associated with dry mouth (P<0.01), earlysatiety (P<0.05), and fatigue (P<0.05).

Conclusions.

1. TSCs preceded CT or RT in almost half of treat-ment-naive patients with solid tumors, notablestronger sweet and salt tastes.

2. Most of those at nutritional risk reported TSCs.3. TSCs were significantly associated with other

symptoms.4. Future research and clinical guidelines, with a

common terminology for assessment, diagnosisand management of cancer TSCs are needed.

What Is a Serious Medical Decision? Patients’And Surrogates’ Perceptions of Serious Decisionsand What Is Important in Making Them (S766)Laura Petrillo, MD, San Francisco Department of Vet-erans Affairs and University of California San Francis-co, San Francisco, CA. Ryan McMahan, BS, University


of California, San Francisco, San Francisco, CA. Re-becca Sudore, MD, San Francisco Veterans Adminis-tration Medical Center and University of California,San Francisco, San Francisco, CA.

Objectives� Identify the types of decisions that patientsencounter and consider serious medicaldecisions.

� Identify personal, spiritual and social influenceson patient and family decision-making, and listdifferences between how patients and surrogatesapproach decision-making.

� Apply awareness of patient perceptions to coun-seling and decision-making support in clinical en-counters with patients and families.

Original Research Background. Most people willface serious medical decisions, yet little is knownabout patients’ and surrogates’ perceptions of deci-sions they have made and how they made them.Research Objectives. To describe the range of real-life decisions people defined as serious and explorethe factors they cited as important in making thosedecisions.Methods. We conducted 13 focus groups withracially and ethnically diverse English- and Spanish-speaking patients and surrogates who reported mak-ing a ‘‘serious’’ decision. Participants were recruitedfrom county and Veterans hospitals, senior centers,and cancer support groups. We used semi-structuredinterviews to ask, ‘‘Think about a time you had tomake an important or serious medical decision,’’and ‘‘Did anything help you make the decision?’’We analyzed the data using qualitative, thematiccontent analysis.Results. The mean age of the 69 participants was 69years (�14), and 29% were African American, 26%white, 26% Asian/Pacific Islander, and 19% Latino.Participants discussed 168 decisions in five categories:1) advance care planning, 23%; 2) cancer treatment,23%; 3) acute medical crises, 21% (e.g., emergencysurgery); 4) chronic illness, 17% (e.g., diabetes man-agement); and 5) transitions, 16% (e.g., transition tohospice). Factors that patients identified as importantin decision-making included: autonomy (38%), medi-cal advice (36%), prior experiences (35%), avoidingsuffering (30%), family opinion (29%), religion(22%), survival (19%), and their own research (16%).Conclusion. Participants considered a full range ofmedical decisions to be serious and important, fromlife-sustaining treatment to diabetes management.They also relied on a variety of factors besides medicaladvice to help them make these decisions.Implications for Research, Policy orPractice. Opportunities exist for decision supportacross the broad spectrum of decisions that patients

and families perceive as serious and important. Suchefforts should be tailored to patients’ values andshould recognize the wide-ranging factors that pa-tients weigh when making decisions.

Palliative Care Core Competencies inUndergraduate Medical Education: MedicalStudent End-of-Life Care Training andExperience with Patient Death at Duke University(S767)Rajiv Agarwal, MD, Duke University Medical Center,Durham, NC. Jason Webb, MD, Duke UniversityHealth System, Durham, NC.

Objectives� Understand the current exposure medical stu-dents receive to the care of dying patients oncore clinical clerkships, such as medicine andsurgery.

� Understand the current curricular challenges forteaching core competencies in undergraduatemedical education, specifically care of the dyingpatient, death pronouncement, and self-reflec-tion after death.

Original Research Background. The currentmethods of teaching medical students culturallyappropriate end-of-life care and palliative carecurricula remain non-standardized due to challengesof integrating palliative care principles into existingmedical education models.Research Objectives. We performed a cross-sectional, observational study to assess end-of-lifecare training and experience with patient death dur-ing clinical rotations for 2nd year (MS2) and 4thyear (MS4) medical students at Duke UniversitySchool of Medicine.Methods. Electronic surveys were generated to assessdemographic- and study-specific questions regardingexposure to palliative care curriculum and patientdeaths. Each participant was assigned a study-specificidentification number, and reviewers of surveys wereblinded for data analysis.Results. Participants included 29 MS2 and 18 MS4students. Ninety-three percent (27/29) of MS2 stu-dents cared for less than five patients who died, and24% (7/29) did not experience a patient death duringtheir core clerkships. While 72% (13/18) of MS4 stu-dents cared for less than five patients who died, 11%(2/18) did not experience a single patient death bygraduation from medical school. Only 21% (6/29)of MS2 and 50% (9/18) of MS4 students witnessed adeath pronouncement and exam being performedby an attending or resident. Seventy-percent (19/27)of MS2 and 89% (16/18) of MS4 students reportparticipating in end-of-life discussions, such as familymeetings, during medical school.


Conclusion. Medical students may be ill prepared tocare for patients at the end of life after medical schooltraining. Medical students at Duke University experi-enced, on average, less than five patients deaths priorto graduation. Few students experienced how to pro-nounce a patient death, and none received any formaltraining in this essential end-of-life skill.

Implications for Research, Policy or Practice. Theresults of our study have significant impact on earlyclinical education in palliative care, with the potentialto lead to future research in curriculum design for un-dergraduate medical education for end-of-life care.

Healthcare Utilization and Costs for SurvivingSpouses Before and After Death in a Population-Based Sample of Individuals with Serious Illness(S768)Katherine Ornstein, MPH PhD, Mount Sinai School ofMedicine, New York, NY. Amy Kelley, MD MS MSHS,Mount Sinai School of Medicine, New York, NY.

Objectives� Describe patterns of healthcare utilization andcosts for spousal caregivers of patients at theend of life.

� Compare healthcare utilization and costs beforeand after bereavement for surviving spouses.

Original Research Background. Family caregiversof patients with serious illness are at risk for poorhealth outcomes. Yet it is unclear how healthcare utili-zation is itself impacted by caregiving, particularly thehigh-stress caregiving that comes when an individual isat the end of life.

Research Objectives. The goal of this study was todetermine healthcare utilization and costs beforeand after death among surviving spouses.

Methods. We used data from the Health and Retire-ment Study, a nationally representative cohort studyof older adults in the United States, which is linkedto Medicare claims data. Our sample consisted of1474 married/partnered dyads over age 65, bothwith fee-for-service Medicare, in which one spousedied between 2002 and 2011. We determined the sur-viving spouse’s healthcare utilization (i.e., emergencydepartment (ED), hospital, and intensive care unit(ICU) admissions) and costs (wage-index adjusted to2012 dollars) at six-month intervals up to two yearsbefore and after their partner’s death.

Results. In the two years before their partner’sdeath, 34% of surviving spouses were hospitalized,compared to 13% after death. ED use was commonbefore and after death (45-49%). ICU use increasedafter death of a spouse from 13% to 18%. Medicarecosts steadily increased in this population over timefrom mean <$2500 18 to 24 months before the part-ner’s death to $5000 18 to 24 months after death.

The vast majority of these spouses served as primarycaregivers, assisting with activities of daily living atthe end of life.

Conclusion. The spouses of individuals who are atthe end of life are themselves high healthcare utilizers.

Implications for Research, Policy or Practice. It isimportant to determine the healthcare utilization andcost trajectories associated with caregiving andbereavement. While there has been significant atten-tion to the current unsustainable level of spendingon healthcare at the end of life, these costs have notaccounted for in the downstream effects on spouses,the majority of whom are also Medicare beneficiari-es.

Development of an Educational InterventionAbout End-of-Life Care Options for Seriously IllAfrican American Patients and Their Caregivers(S769)Ramona Rhodes, MD MPH MS, University of TexasSouthwestern Medical, Dallas, TX. Ethan Halm, MD,University of Texas Southwestern Medical Center, Dal-las, TX. Celette Sugg Skinner, PhD, University of TexasSouthwestern Medical Center, Dallas, TX.

Objectives� Identify specific barriers to completion ofadvance care planning and hospice enrollmentamong members of the African Americancommunity.

� Describe the development of a video interventiondesigned to inform seriously ill African Americanpatients and their caregivers about advance careplanning, palliative care, and hospice.

Original Research Background. Research hasshown that African Americans (AAs) are less likely tocomplete an advance directive and enroll in hospiceat the end of life. Despite numerous studies that iden-tify specific barriers to end-of-life care for AAs, there islittle research dedicated to the design and implemen-tation of interventions to address these issues.

Research Objectives. Describe development andadaptation of a culturally sensitive video interventiondesigned to increase knowledge and awareness ofand address barriers to advance care planning, pallia-tive care, and hospice among seriously ill AA patientsand their caregivers.

Methods. Semi-structured, video-recorded interviewswere conducted with six AA providers and recipientsof hospice and/or palliative care (a physician, nursepractitioner, minister, patient, and two caregivers)that addressed previously identified barriers to end-of-life care. From these interviews, we selected tar-geted video clips, and combined them with culturallyappropriate graphics and narration. Resulting videocomponents were viewed by focus groups comprised


of providers (hospice/palliative care and geriatrics)and community-dwelling African Americans whowere patients or caregivers of patients who receivedcare at our University-affiliated hospitals or clinics.Results. Focus group participants indicated thatincreasing awareness of various care options for AAsis important, and culturally sensitive interventiondevelopment is needed. Feedback obtained addressedappropriateness, understanding, and acceptability ofmessaging, topic areas, and length of the video. Weused participants’ feedback to modify the video clips,graphics, and narration to facilitate greater under-standing and acceptability.Conclusion. This video intervention proved accept-able to the patients, caregivers, and healthcareworkers who provided input. Feasibility and accept-ability of the modified intervention will now be testedamong seriously ill AA patients and their caregivers.Implications for Research, Policy orPractice. While previous research has identified bar-riers to end-of-life care among members of underrep-resented groups, this study is among a small numberstudies of which we are aware to operationalizeresearch findings into intervention components ad-dressing these barriers.

Aid to Our Front Line Warriors: A Brief End-of-Life Communication Curriculum for InternalMedicine Interns (S770)Katie Stowers, DO, University of Texas Health ScienceCenter at San Antonio, San Antonio, TX. RadamesMartinez, MD, University of Texas Health ScienceCenter at San Antonio, San Antonio, TX. Sandra San-chez-Reilly, MD FAAHPM, University of Texas HealthScience Center, San Antonio, TX.

Objectives� Describe the components of a brief end-of-lifecommunication skills training curriculum.

� Recognize the benefit of a brief communicationtraining session using a multimodal teachingapproach including didactic, simulation andfeedback.

Original Research Background. Internal medicineinterns (interns) are the physicians spending themost time with hospitalized patients, frequentlyassisting with end-of-life (EOL) decision-making.However, most report feeling ill-equipped forthese situations. Multimodality hands-on training,including didactics, practice and feedback, havebeen effective in improving skills/ confidence inEOL communication.Research Objectives. To assess a brief hands-onEOL communication curriculum for interns (PC-I).Methods. Interns (n¼24) participated in PC-Icomprised of a one-hour didactic, a one-hour role

play, and two observed structured clinical encounters:Breaking Bad News (BBN), Family Meeting (FM) withreal-time evaluation (skills checklist/ written com-ments), and preceptor feedback. Self-Efficacy in Palli-ative Care (PC) Communication sub-section (SPEC-C)evaluated pre/post curriculum self-assessment ofcompetence. Participants provided subjective post-cur-riculum impressions.Results. 45.8% had no prior PC training. BBN andFM checklist mean score was 32.2 /45 (Min 18, Max41, SD 4.67), and 26.6 /39 (Min 15, Max 38, SD6.12), respectively. Checklist-identified improvementthemes: 1) introducing PC; 2) assessing patient/familydesire for prognostic knowledge; 3) exploring pa-tient/family emotional state; and 4) summarizing dis-cussion. Preceptor feedback identified fourimprovement themes: 1) setting meeting agenda‘‘warning-shot’’; 2) avoiding medical jargon; 3) discus-sing prognosis; 4) appropriate utilization of surrogatedecision-maker. Intern impressions identified four ma-jor themes: 1) safe environment for skills practice; 2)confidence to perform skills in clinical setting; 3)valued feedback; 4) patients/families appreciatedirect conversations about death/dying and prog-nosis. SPEC-C showed improvement in self-perceivedconfidence discussing patient’s death with patient(p<0.05), with family (p¼0.07), with family duringbereavement (p<0.05).Conclusion. A brief, hands-on, multimodality EOLcommunication curriculum is a valuable learningexperience for interns at early stages of their career,which can improve confidence and identify specificareas for continued skill development.Implications for Research, Policy orPractice. Further research is needed to assess long-term impact of brief communication curriculum as itpertains to improved clinical outcomes.

What Helps and Hinders Oncologists fromConducting Goals-of-Care Conversations? (S771)Dena Schulman-Green, PhD, Yale University School ofNursing, West Haven, CT. Cardinale Smith, MD MSMSC MSCR, Icahn School of Medicine at Mount Sinai,New York, NY. Jenny Lin, MD MPH, Icahn School ofMedicine at Mount Sinai, New York, NY. Shelli Feder,RN MSN FNP-BC, Yale University, New Haven, CT.Nina Bickell, MD MPH, Icahn School of Medicine atMount Sinai, New York, NY.

Objectives� Identifyfive facilitatorsofgoals-of-careconversations.� Identify five barriers of goals-of-care conversations.� Identify three remediable barriers of goals-of-careconversations.

Original Research Background. Goals-of-care(GoC) conversations reduce hospital and ICU


admissions while improving quality of life, yet only37% of advanced cancer patients report havinghad them, and most happen near the very end oflife.

Research Objectives. To describe oncologists’ per-spectives on facilitators of and barriers to GoC conver-sations with patients with advanced cancer.

Methods. Semi-structured interviews with oncologistsat academic, community, and municipal hospitals(n¼4) in New York and Connecticut. Topics includeapproach to GoC conversations, facilitators, barriers,and organizational influences. We analyze data usinginterpretive description.

Results. Participants to date (n¼12 of 25) are 83%male, they have a mean age of 45 (range 32-66)and 18 years (range 6-40) in practice, and 50%received training in GoC. Facilitators of GoC conver-sations include patient characteristics of higherhealth literacy and poor functional status and havinga supportive practice environment (e.g., palliativecare resources). Barriers include patient characteris-tics of being young and newly diagnosed, patient-fam-ily conflict, and physicians’ emotions. Although mostparticipants felt GoC conversations should beongoing, some reported two distinct conversations:an early ‘‘introductory’’ conversation about cancer ba-sics and treatment goals and a ‘‘near the end’’ con-versation about risks and benefits of furthertreatment and DNR. These conversations haddifferent triggers. Perceived best timing of GoC con-versations varied by subspecialty.

Conclusion. While data collection is ongoing, wehave identified facilitators of and barriers to GoCconversations, some of which may be remediableby enabling oncologists to conduct GoC conversa-tions despite difficult circumstances andemotional reactions, activating patients/family viaincreasing health literacy or peer support, advancingpalliative-informed practice environments, andcreating subspecialty-specific guides for timing ofGoC conversations. Analyses are underway to helpclarify the two distinct content conversations andconnections between them.

Implications for Research, Policy or Practice. Byaddressing findings in Oncotalk, a program to trainoncologists in palliative care skills, we hope to improvecontent and timing of GoC conversations.

Hearing Loss in the Last Two Years of Life: APopulation-Based Study (S772)Alexander Smith, MD MPH MS, University of Califor-nia, San Francisco, San Francisco, CA. Christine Ritch-ie, MD MSPH, FAAHPM, University of California, SanFrancisco, San Francisco, CA. Margaret Wallhagen,

GNP PhD, University of California, San Francisco,San Francisco, CA.

Objectives� Describe the prevalence of hearing loss duringthe last two years of life.

� Describe factors associated with hearing loss inthe last two years of life.

Original Research Background. Epidemiologicdata on the prevalence of hearing loss near death islacking.

Research Objectives. To assess the prevalence andcorrelates of hearing loss during the last two years oflife.

Methods. We used the Health and Retirement Study,a longitudinal population-based cohort of adults age>50 followed through death (2000 to 2013). Theinterview within the two years closest to death wasused. Participants were asked to rate their hearing(excellent, very good, good, fair, or poor). We usedsurvey weights to describe the population prevalenceand correlates of fair/poor ratings in the two yearsbefore death and in six-month increments prior todeath.

Results. Of 5895 participants (mean age at death 78years; 53% women, 20% non-white), overall, 32%rated their hearing as fair/poor (95% CI 31-34%).The prevalence of fair/poor hearing increased asdeath approached (29% 19-24 months prior to death;36% 1-6 months prior to death; p for trend ¼ 0.01).Correlates of fair/poor hearing during the last twoyears of life included: age at death (prevalence offair/poor hearing by age: 50-59 22%, $90 50%),gender (men 35%, women 30%), ethnicity (Latino42%, white 33%), wealth (lowest quartile 38%, highestquartile 27%), history of heart disease (yes 38%, no27%), dependence in activities of daily living (yes42%, no 26%), and probable dementia (yes 44%, nocognitive impairment 24%).

Conclusion. Hearing loss is increasingly common asdeath approaches, and it is associated with physical,cognitive, and social vulnerability.

Implications for Research, Policy orPractice. Research is lacking. New strategies toscreen for and manage hearing loss in diverse popu-lations of dying older adults are needed. Medicareshould cover a range of hearing services in theelderly, including hearing aids, not just expensivecochlear implants.

What are the Facilitators of Public Reporting ofHospice Quality? (S773)Randall Gale, DPH, Veterans Administration VA PaloAlto Healthcare System, Menlo Park, CA. Dale Lupu,PhD, George Washington University, Washington,


DC. Donna Infeld, PhD, The George Washington Uni-versity Hospital, Washington, DC. Marsha Regenstein,PhD, George Washington University, Washington, DC.

Objectives� Understand hospices’ preparation for public re-porting of quality data.

� Understand attitudes towards the voluntarydisclosure of hospice quality data.

Original Research Background. The AffordableCare Act requires submission of hospice quality datato the Centers for Medicare and Medicaid Services(CMS). Since 2014, hospices have been submittingthe hospice item set and collecting experience-of-care data. CMS has not set a date for releasing datain a ‘‘hospice report card.’’ Some have advocated thevoluntary release of data, while others have advocatedwaiting for CMS to make data public.Research Objectives. Explore attitudes towards andpreparation for public reporting and identifying bar-riers and facilitators.Methods. Web-based survey of US hospices fieldedduring 2012 supplemented with 15 interviews withnon-hospice provider stakeholders. Logistic regressionto predict: (1) odds of hospices identifying a need forCMS reporting, and (2) their willingness to publiclyshare data ahead of CMS’ public release. Predictor var-iables were hospice size, tax status, EMR implementa-tion, and use of the Family Evaluation of Hospice CareSurvey.Results. 390 of 1451 hospices (26.9%) responded tothe survey. Hospices were confident in their abilityto comply with the public reporting mandate; the ma-jority (71.5%) believed CMS reporting is needed. For-profit and smaller hospices were significantly less likelyto see the need for reporting; hospices with full EMRimplementation were more likely than others to sup-port reporting (OR ¼ 2.581). Hospices were willingto consider voluntarily sharing quality data; otherstakeholders worried consumers won’t use the dataand emphasized the need for careful measurespecification.Conclusion. As the plan to publicly disclose hospicequality data evolves, CMS and the hospice industrywill benefit from careful consideration of the mostappropriate measures and how those measures canbest serve multiple stakeholders. Continued invest-ments in EMRs will likely facilitate hospices’ abilityto measure, monitor, and report on performance.Implications for Research, Policy orPractice. Researchers and practitioners must workclosely with policymakers to ensure optimal imple-mentation of a program that maximizes uses of thedata and minimizes unintended consequences.

Hospice Staff Perceptions of Communicationswith Seriously Ill Individuals and Families Priorto Hospice Enrollment (S774)Hyunjin Noh, PhD MSW, The University of Alabama,Tuscaloosa, AL.

Objectives� Show an increased level of knowledge about infor-mation provided by hospice admissions staff dur-ing pre-enrollment meetings with seriously illindividuals and families.

� Show an increased level of knowledge aboutcommunication needs seriously ill individualsand families express during pre-enrollmentmeetings.

Original Research Background. Hospice care pro-viders’ communication with seriously ill individualsand families prior to enrollment in hospice care hasreceived little attention. Prior research consistently re-ported lack of knowledge about hospice as one of themajor contributing factors of lower rates of hospiceuse among general populations and particularlyamong racial/ethnic minorities. Visits by hospice ad-missions staff with seriously ill individuals/familiesprior to the receipt of services may be able to clarifymisunderstandings and increase the level of knowl-edge about hospice care services so that informed de-cisions are possible.Research Objectives. This qualitative study exploredhospice care providers’ perceptions of communica-tion with seriously ill older individuals and their fam-ilies during pre-admission visits.Methods. Individual, face-to-face interviews were con-ducted with fifteen hospice admissions staff members.Open-ended questions were asked about the focus ofcommunication and perceived communication needsof older individuals/families that were referred forhospice care. Thematic analysis of the interview tran-scripts was conducted.Results. Themes from the analysis revealed that thecommunication during pre-enrollment visits centeredon tailored information about the individual’s diagnosisandhospice services that could address specific individualand family needs. Communication needs were identifiedregarding clarification of common misunderstandingsabout artificial nutrition/hydration and fears and con-cerns about administration of pain medications. In addi-tion, need for further discussion with doctors aboutdiagnosis and prognosis of the illness was discussed.Finally, eventual decisions to enroll in hospice tended tobe influenced by different cultural family dynamics.Conclusion. Educational needs in understanding theillness and comfort care measures were identified inthis study.


Implications for Research, Policy orPractice. Hospice care providers can use pre-admis-sion visits as an opportunity to promote accurate un-derstanding of hospice care and to relieve seriouslyill individuals’ and families’ anxiety in this often diffi-cult decision-making process. Also, in-depth discus-sions with doctors regarding diagnosis/prognosisand end-of-life care options are needed for easier tran-sition to hospice care.

How Come They Don’t Come? IdentifyingReasons of No-Shows Among a Palliative CareOutpatient Clinic (S775)Sherry Williams, MD, University of Texas Health Sci-ence Center at San Antonio & South Texas VeteransHealth Care System, San Antonio, TX. Shuko Lee,MS, South Texas Veterans Health Care System, SanAntonio, TX. Jennifer Healy, DO, University of TexasHealth Science Center at San Antonio, San Antonio,TX. Sandra Sanchez-Reilly, MD FAAHPM, Universityof Texas Health Science Center, San Antonio, TX.

Objectives� Assess factors affecting no-shows of patients to anoutpatient palliative care clinic.

� Discuss potential solutions to decrease no-showsamong palliative care patients who need thefollow-up.

Original Research Background. Palliative Care(PC) patients often experience complex distress thatis better addressed by an interdisciplinary PC outpa-tient clinic then by standard outpatient care. PC pa-tients, like many clinic patients, do not always keepappointments. These no-shows (NS) are missed ap-pointments with no prior cancellation notice.

Research Objectives. To assess factors that correlatewith PC patients missing clinic appointments.

Methods. A telephone survey was performed for pa-tients that were NS for clinic appointments fromNovember 2014-April 2015. Information obtainedfrom patients or caregivers. A telephone script with19 questions was used.

Results. N ¼76. Female¼39. 38 agreed to participatein the telephone survey, 21 declined participation,and 17 had non-working phone numbers. Reasonsidentified for NS: 10 hospitalized, seven deceased,six too sick, three hospice, five never seen in clinic/didn’t know reason to attend, four no reminder call,one transportation issues, and two denied missing.13/14 patients reported prior visit as beneficial. Iden-tified benefits were: managing pain, symptoms andspiritual concerns with prior visit.

Conclusion. Patients with NS had many reasons formissed appointments, such as hospital admissions,symptom burden, and not understanding/knowingabout clinic appointment. Developing a more

systematic appointment reminder system might helpus free up appointments for other patients and re-move deceased, hospitalized/hospice patient’s andmake those patients who are unaware of appointmentbetter informed. Also close follow-up phone calls afterNS might help by triaging symptoms or issues that leadto NS and might improve patient care.

Implications for Research, Policy orPractice. Evaluating NS can make PC clinics moreefficient, expand reach to greater number of patients,and reduce patients lost to follow-up and sufferingfrom untreated symptom burden and spiritual dis-tress.

Protecting Our Vulnerable Population: Screeningfor Mistreatment in Palliative Care (S776)Heather Veeder, MD, University of Texas Health Sci-ence Center at San Antonio, San Antonio, TX. KatieStowers, DO, University of Texas Health Science Cen-ter, San Antonio, TX. James Linden, Medical Student,University of Hawaii at Manoa, Honolulu, HI. ShukoLee, MS, South Texas Veterans Health Care System,San Antonio, TX. Sandra Sanchez-Reilly, MDFAAHPM, University of Texas Health Science Center,San Antonio, TX.

Objectives� Discuss the impact of mistreatment amongvulnerable palliative care patients.

� Recognize the need to improve awareness andidentification of mistreatment in palliative carepopulations.

Original Research Background. Palliative Care(PC) patients are a vulnerable population. While theincidence of mistreatment in other vulnerable popula-tions has been defined, approaching 10% of theelderly and 50% of those suffering from dementia,the incidence of mistreatment in PC not well defined.

Research Objectives. To assess rate of PC patientswho establish concern for mistreatment (ECM) andidentify its risk factors

Methods. Patients seen by the PC clinical service of atertiary hospital (inpatient and outpatient) werescreened for mistreatment over 30-day period usingtwo mistreatment screening tools validated amongelderly: Elder Abuse Suspicion Index (EASI) andCaregiver Abuse Screen (CASE). Patients able toparticipate in a survey were screened using EASI. Care-givers were screened with CASE if patient was unableto participate or reported relying on caregiver. EASIscore $1 (max 6) and CASE $4 (max 8) ECM.

Results. N¼ 64 (47 inpatients, 17 outpatients, all withcommon PC diagnosis). 58% female; 11% elderly;53% Hispanic; 63% with cancer diagnosis; 55% relyon caregiver. Forty-five completed EASI only, fourCASE only, and 15 both. Eleven (17.19%) were ECM


cases. A significant relationship was found betweenpresence of PC diagnoses and ECM, [p ¼ 0.01].EASI question #2 (preventing access to resources/peo-ple/medical care, p¼0.02), #3 (verbal shaming,p<0.001) and CASE question #2 (caregiver shamefulof actions, p¼0.005), #4 (caregiver acting rough,p¼0.02), and #7 (caregiver exhaustion, p¼0.006)were significant to ECM.Conclusion. The rate of PC patients who ECM issimilar to other vulnerable populations. ECM risk fac-tors included PC diagnoses; further risk factor identi-fication was limited by small sample size and variableapplicability of elderly-targeted, validated scales.Implications for Research, Policy orPractice. Larger scale studies are needed to identifyrisk factors for PC mistreatment and to develop vali-dated PC mistreatment screening tools, ultimatelyimproving patient care for vulnerable PC patientsand targeting risk factors such as caregiver burden.

Impact of a Pediatric Palliative Care Team onLimitations of Care for Inpatients at a Free-Standing, Tertiary-Care Children’s Hospital(S777)Christopher Plymire, MD, A.I. duPont Children’s Hos-pital, Wilmington, DE. Elissa Miller, MD, Nemours/A.I. duPont Children’s Hospital, Wilmington, DE.Meg Frizzola, DO, Nemours, Wilmington, DE.

Objectives� Understand the role of pediatric palliative care inend-of-life discussions.

� Identify further opportunities for do-not-resusci-tate (DNR) research and analysis of advancedcare planning in pediatrics.

Original Research Background. Discussions sur-rounding limitations of care can invoke controversy,confusion, and anxiety in both healthcare profes-sionals and families. Some literature exists regardingthe impact of pediatric palliative care teams on ICUadmission, cost, and family satisfaction. Limited infor-mation, however, is available regarding the factorsinvolved in end-of-life decisions. Understanding thesefactors may improve the process of evaluating andplacing limitation-of care orders in children.Research Objectives. Our study aims to analyze thetiming of DNR order placement prior to death in pe-diatric patients. We also aim to further delineate thespecialty of the ordering physician, demographicdata, and location of death.Methods. We present a retrospective review of 471deaths between 1/2009 and 10/2014. The palliativecare team was established in September, 2011. Forthose patients who had a DNR order in place, weanalyzed patient and physician characteristics as wellas DNR order timing.

Results. The location of death of 49% of patients whohad a DNR in place was in an ICU setting. The deathrate in the ICU was not statistically different followinginitiation of the palliative care team (PCT) (p¼0.53).The overall DNR rate increased following initiationof the PCT from 30.8% to 39.2% (p¼0.05). The PCTwas consulted in 77% of deaths and ordered theDNR in 60% of children.Conclusion. Our results emphasize the importantrole of the palliative care team during end-of-life dis-cussions in children. The palliative care team metwith more than three quarters of families prior todeath, and they placed the DNR order in more thanhalf of these instances. The initiation of the palliativecare team was associated with a large increase in over-all DNR rates.Implications for Research, Policy orPractice. Additional studies are needed in pediatricsto further delineate the timing of palliative careconsultation in the patient’s overall course of illness,demographic and cultural influences, and specific pa-tient conditions, such as tracheostomy dependence.

Unintended Consequences: Exploring the Effectson Palliative Care Outpatients of Recent Changesin Florida Laws for Prescribing Controlled PainMedications (S778)Chad Kollas, MD FACP FCLM FAAHPM, University ofFlorida Health Cancer Center at Orlando Health, Or-lando, FL. Beth Kollas, PhD, YMCA of Central Florida,Orlando, FL.

Objectives� Understand the changes in Florida laws thatgovern prescribing controlled pain medicationsthat took place beginning in 2010.

� Identify the positive and intended outcomes fromFlorida’s enforcement action against ‘‘Pill Mills’’and its new pain laws.

� Identify the unintended negative outcomes fromFlorida’s enforcement action against ‘‘Pill Mills’’and its new pain laws.

Original Research Background. In 2010, Floridaimplemented plans to reduce opioid misuse andrelated deaths by eliminating rogue pain clinics or‘‘Pill Mills.’’ Its new laws explicitly avoided limitationson prescribing controlled medications for cancer-related pain.Research Objectives. To assess Florida’s efforts toeliminate ‘‘Pill Mills’’ and restrict prescribing ofcontrolled pain medications for chronic nonmalig-nant pain, including effects on patients receivingoutpatient palliative care at a university-affiliatedcomprehensive cancer treatment center.Methods. We reviewed state and federal governmentreports on prescription drug deaths, print and


television media reports, and cancer center pharmacyshortage reports, and we interviewed cancer centeroutpatients about their experiences.

Results. Between 2010 and 2014, the number ofregistered pain clinics in Florida decreased frommore than 900 to 367. The death rate from prescrip-tion drug overdoses in Florida fell by 23 percentfrom 2010 to 2012. From 2013 to 2014, however,deaths from heroin-related overdoses increased 84percent. From November 2012 until September2014, the outpatient pharmacy at our cancer centerexperienced monthly shortages of opioid analgesics,most often 15- and 30-mg tablets of oxycodone. Theseshortages occurred in the last seven to 10 days of eachmonth, and about one-third of clinic patients reportedvisiting three to four alternate pharmacies to fill theirprescriptions. By early 2015, a special series of reportstelevised patients’ difficulties in filling legitimate pre-scriptions for controlled pain medications, includingseveral pharmacies’ denial of pain medications toterminally ill cancer patients. About one-fifth of outpa-tients in our palliative care clinic reported similar chal-lenges obtaining pain medications.

Conclusion. Florida’s action against ‘‘Pill Mills’’ andopioid analgesic abuse were associated with a 23percent reduction in deaths from prescription drugoverdoses, but these efforts were also associated withan 84 percent increase in heroin deaths. Despite aclear legislative intent to protect cancer patients,many terminally ill cancer patients experienced Flori-da’s denials for prescriptions for legitimate painmedications.

Implications for Research, Policy orPractice. Well-intended efforts to reduce prescriptiondrug misuse and diversion may result in unintendedconsequences that can be harmful to vulnerable pa-tient populations, such as those receiving outpatientpalliative care.

A Comparison of Continuing Bonds Over Time inBereaved Parents and Siblings After the Death ofa Child (S779)Terrah Foster Akard, RN CPNP PhD, Vanderbilt Uni-versity Medical Center, Nashville, TN. Mary Dietrich,PhD, Vanderbilt University, Nashville, TN. MarissaBaudino, MEd, Vanderbilt University, Nashville, TN.Arianna Stone, BA, Vanderbilt University, Nashville,TN.

Objectives� Compare purposeful and non-purposefulcontinuing bonds between one and two yearspost-death.

� Compare comforting and discomforting effects ofcontinuing bonds between one and two yearspost-death.

Original Research Background. Continuing bondsrefer to bereaved individuals maintaining connectionswith the deceased. Continuing bonds have beendescribed as a coping strategy for bereaved individ-uals, but few studies have compared similarities anddifferences in how bonds evolve over time.

Research Objectives. This study compared reportsof continuing bonds from bereaved parents and sib-lings at one (T1) and two (T2) years after the deathof a child to cancer.

Methods. Twenty-six families participated in bothyears of the study. Participants included mothers (n ¼21), fathers (n ¼15), and siblings (n ¼ 25). Semi-struc-tured home interviews using open-ended questionswere conducted with parents and siblings separately.Content analysis identified emerging themes andincluded counts and frequencies of participant re-sponses. McNemar tests examined differences in thefrequency of responses between T1 and T2 data.

Results. Similar to participants’ reports at one yearpost-death, themes emerging from participants’ re-ports at two years post-death included purposeful(e.g., visual representations of the deceased, visitingthe cemetery, communicating to the deceased) andnon-purposeful (e.g., dreams about the deceased,visits/signs from the deceased) continuing bondsand comforting and discomforting effects. Frequencyreports of each category at T1 and T2 will be pre-sented. Comparisons between T1 and T2 data werenot statistically significant.

Conclusion. Reports of continuing bonds frombereaved parents and siblings after the death of achild are similar at one and two years post-death.Continuing bonds may be a long-term coping strategyused by bereaved individuals.

Implications for Research, Policy orPractice. Providers should be mindful to assesscontinuing bonds with bereaved families and awarethat effects can be both comforting and discomfort-ing. More research is needed to determine how tofacilitate positive effects from continuing bonds andwhether interventions to promote bonds could behelpful.

Impact of an Interprofessional Training Programin Pediatric Palliative Care on InterprofessionalCompetencies and Career Development of FormerFellows (S780)Shih-Ning Liaw, MD, Dana-Farber Cancer Institute,Boston, MA. Amy Sullivan, EdD, Harvard MedicalSchool, Boston, MA. Marsha Joselow, MSW LICSW,Boston Children’s Hospital/Dana-Farber Cancer Insti-tute, Boston, MA. Janet Duncan, MSN CPNP, BostonChildren’s Hospital/Dana-Farber Cancer Institute,


Boston, MA. Joanne Wolfe, MD MPH FAAHPM, Dana-Farber Cancer Institute, Boston, MA.

Objectives� Identify benefits and challenges of interprofes-sional education in pediatric palliative care at apost-graduate level.

� Evaluate career trajectories of pediatric palliativecare fellows after fellowship.

Original Research Background. Interprofessionaleducation (IPE) has been recognized as foundationalto preparing clinicians for collaborative practice andenhanced patient care. While practice standards forpediatric palliative care (PC) utilize a team-based,interprofessional model, standards for pediatric IPEhave not been established.Research Objectives. This study is the first to reportoutcomes of an interprofessional fellowship programin pediatric PC. The objectives were to evaluate theimpact of the program on former fellows’ interprofes-sional competencies and career progression.Methods. Fellows who participated in the programbetween 2002 and 2014 were surveyed about theirfellowship experience, perceived change in interpro-fessional skills, and career paths post-fellowship. The10 interprofessional competencies surveyed wereadapted from core competencies issued by the Inter-professional Education Collaborative, spanning thedomains of values and ethics, roles and responsibil-ities, interprofessional communication, andteamwork.Results. Of the 29 fellows, 27 (93%) responded.Fifteen (56%) were physicians, five (19%) were nursepractitioners, and seven (26%) were social workers.Respondents reported significant improvements inall 10 interprofessional competencies, with summedmean scores of 2.8�0.6 pre-fellowship (representing‘‘not very well prepared’’) and 4.4�0.4 post-fellowship(‘‘very well prepared’’ to ‘‘extremely well prepared’’) (t¼13.8, p<.0001). Respondents reported significantcareer changes, including increased specialization inPC (4% vs. 70%) and academic focus (26% vs. 55%).Compared to pre-fellowship clinical practice, respon-dents reported increased involvement in interprofes-sional teams (53% vs. 100%), with 81% in PC teamsand 35% in hospice teams. Qualitative analysis ofopen-ended responses illustrated that fellows experi-enced professional growth in a rich educational envi-ronment highlighted by dynamic interprofessionalrelationships, scaffolded clinical instruction, andexpert mentorship. Although complex team dy-namics, inefficiency, and differences in educationalneeds were identified as challenges in IPE, all respon-dents reported that the benefits of IPE outweigh thenegatives.

Conclusion. This study demonstrates that interpro-fessional training in pediatric PC is feasible and effec-tive in developing clinicians skilled ininterprofessional practice.

Benefits of Palliative Care in the MICU (S781)Bethany Kapp, MD, University of Texas Health ScienceCenter at San Antonio, San Antonio, TX. ChristinaMireles, MD, University of Texas Health Science Cen-ter at San Antonio, San Antonio, TX. Sandra Sanchez-Reilly, MD FAAHPM, University of Texas Health Sci-ence Center at San Antonio, San Antonio, TX. Jenni-fer Healy, DO, University of Texas Health ScienceCenter San Antonio, San Antonio, TX. Shuko Lee,MS, South Texas Veterans Health Care System, SanAntonio, TX.

Objectives� Assess the effects of a palliative care consultationservice in ICU admissions, cost savings and lengthof stay.

� Discuss benefits of palliative care in the ICUsetting.

Original Research Background. It has already beendocumented that inpatient palliative care consultation(PCC) can reduce both length of hospitalization andinpatient costs among seriously ill individuals whoare admitted to the intensive care unit (ICU). More in-formation on the cost impact of ICU PCC maycontribute to additional support from hospital admin-istrators and ultimately lead to more resources to carefor terminally ill patients.Research Objectives. To compare ICU admissionrates, ICU readmission rates and inpatient costs for pa-tients who received a PCC vs. matched patients whoreceived usual standard of care.Methods. We analyzed de-identified data for a 40-month period (January 2012 to April 2015), includingall patients admitted to the MICU at a teaching ter-tiary county hospital. Of the 86,131 hospital admis-sions, there were 1449 patients with 3829 visits to theMICU. We matched PC patients with standard care(SC) patients using DRG and discarded those withoutat least three matches. N¼1347 matched MICU pa-tients. 40% were female. 931/1347 patients had aPCC.Results. There was a statistically significant decreasein PPC group with median length of stay of ninedays vs. 15 days in the non-PCC group (p<0.0001).Difference in mean total charges was $79,348 withnon-PCC group at $196,293 vs. PCC-group at$116,945 (p<0.0001). There was a non-significanttrend for decreased repeat ICU admissions with PCCgroup mean ¼ 1.05 and non-PCC group mean ¼1.08 (p¼0.089).


Conclusion. This study revealed that ICU PCCdecreased both length of stay and inpatient costs.Although not significant, this study also revealed thatrepeat ICU admissions trended down with ICU PCC.

Implications for Research, Policy orPractice. PCC can be an effective way to reducehealthcare expenditures in critically ill patients, andfurther studies are needed to determine specificPCC benefits among patients with specific diagnoses.

Awareness of Medical Orders for Life-SustainingTreatment and Non-Hospital, Do-Not-Resuscitate(DNR) Orders Among Primary CarePediatricians (S782)Tarek Zetoune, MD, Montefiore Medical Center,Bronx, NY. Lily Lew, MD, Flushing Hospital MedicalCenter, Flushing, NY. Dakshayani Guttal, MD, JamaicaHospital Medical Center, Jamaica, NY. SusanaRapaport, MD, Flushing Hospital Medical Center,Flushing, NY. Rohit Pinto, MD, Flushing HospitalMedical Center, Flushing, NY.

Objectives� Understand disparities in outpatient DNR/DNIorders among primary pediatricians.

� Understand the need for education about outpa-tient DNR/DNI discussions.

Original Research Background. With the recentannouncement of Medicare to reimburse physiciansfor talking with patients about end-of-life options, lit-tle is known about the awareness of pediatricians inoutpatient do-not-resuscitate/do-not-intubate (DNR/DNI) discussions.

Research Objectives. Assessing the knowledge, utili-zation and experience of primary care pediatricians(PCPs) with outpatient Medical Orders of Life Sustain-ing Treatment (MOLST) and Non-Hospital-DNR(NH-DNR) orders.

Methods. A survey was distributed in person or byemail to PCPs affiliated with three urban teachingcommunity hospitals. Demographic data, awarenessof MOLST, NH-DNR, New York State DNR (NYS-DNR) bracelet, and palliative care specialist werecollected.

Results. Of 45 physicians who responded to the sur-vey, three were not practicing in a primary care settingand were excluded. From the total number of PCPs,55% were female and 48% described their ethnicityas Asian or Pacific Islander. 78% were >45 years ofage, 64% were practicing >15 years, and 62% saw<250 patients each month. Only 12% had previouslyissued an outpatient DNR. 83% were unaware ofNYS-DNR bracelet. 67% were not comfortable withDNR discussion. 83% preferred an outpatient pallia-tive care referral for DNR discussion. 74% favoredformal training in outpatient DNR discussion. 57%

would discuss DNR only when asked by guardian;36% would only discuss DNR with terminally ill pa-tients, patients residing in long-term care facility, orall patients requiring long-term care services; and7% would discuss DNR in other circumstances. Thereasons for not issuing outpatient DNR were: 84%said there was no appropriate patient, 8% were un-aware that outpatient DNR was valid in NYS, and 8%cited other reasons.

Conclusion. More than half of PCPs felt that theywere unprepared for and not comfortable with discus-sions about resuscitation.

Implications for Research, Policy orPractice. There is definitely recognition for palliativecare providers that might suggest a change in thefocus of teaching and education around palliativecare from inpatient to outpatient settings.

Responding to Urgency of Need in PalliativeCare: Initial Stage of Development of a DecisionAid for Palliative Care Triage (S783)Beth Russell St. Vincent’s Hospital Melbourne, Mel-bourne, VIC, Australia. Nicole Hennessy Anderson,BSocSc (Psych)(Hons), Centre for Palliative Care,Mount Waverley, VIC, Australia. Anna Collins, MHealth Psych, St. Vincent’s Hospital Melbourne, Mel-bourne, VIC, Australia. Brian Le, MBBS MPH FRACPFAChPM, The Royal Melbourne Hospital, Parkville,VIC, Australia. Jennifer Philip, MBBS, Centre ForPalliative Care Education & Research, Fitzroy, VIC,Australia.

Objectives� Comprehend the factors that indicate urgency ofpalliative care needs.

� Articulate the challenges and barriers associatedwith the triage process in palliative care.

Original Research Background. Demand for inpa-tient and community-based palliative care (PC) isgrowing. This trend is due to an aging population,earlier integration of PC in cancer care, increasinginvolvement of PC in non-malignant disease, andincreasing community awareness of palliative care.Thus a diverse patient population referred from a va-riety of sources must be triaged for allocation oflimited clinical resources.

Research Objectives. The aim of this study was toexplore the experience of health professionals whentriaging PC needs as an initial step in developing a de-cision aid that can facilitate the equitable, efficientand transparent allocation of PC services by urgencyof need.

Methods. Twenty purposive-sampled general andspecialist PC health professionals (medical n¼9,nursing n¼9, allied health n¼2) from metropolitanand regional locations across Victoria, Australia


participated in focus groups or individual interviews. Asemi-structured interview guide sought to explore per-spectives on indicators of urgency and facilitators andbarriers to implementation. Transcripts were sub-jected to deductive thematic analysis by tworesearchers.Results. Health professionals shared commonality inthe factors they found useful to determine urgency,such as current or impending mismatch betweencare needs and care environment. Performance statuswas reported to be less important when considered inisolation. Interpersonal and ethical challenges associ-ated with the triage process and systemic barriers forimplementing a decision aid were highlighted.Conclusion. Indicators of urgent PC needs are com-plex, dynamic and often inter-related, but are usefulfor PC health professionals undertaking the difficulttask of triage. The results of this study will form the ba-sis of a future discrete choice experiment to deter-mine the relative importance of each triage factor.Implications for Research, Policy orPractice. This study will have important implicationsfor the development of a decision aid that will enablea standardized approach to ensuring equitable, effi-cient and transparent PC service allocation.

Yes, I Can Live with Less Pain: A PainEducational Intervention Improving Patient-Centered Care and Attitudes Among Older Adults(S784)Linda May, MD, University of Texas Health ScienceCenter at San Antonio, San Antonio, TX. SandraSanchez-Reilly, MD FAAHPM, University of TexasHealth Science Center at San Antonio, San Antonio,TX. Edggar Frausto, MD, University of Texas HealthScience Center at San Antonio, San Antonio, TX.Shuko Lee, MS, South Texas Veterans Health CareSystem, San Antonio, TX. Jessica Garcia, DO,Symptom Management Consultants, Houston, TX.

Objectives� Discuss how a patient-centered educational inter-vention may improve attitudes towards pain man-agement among older adults.

� Demonstrate the impact of an outpatient-centered educational intervention in future deci-sions related to pain medication utilization.

Original Research Background. Uncontrolledchronic pain is very common among older adults(OA). Pain is a complex symptom with subjective mea-surements that is also difficult to manage due to socialstigma related to treatment.Research Objectives. To assess if case-based, low-lit-eracy educational interventions may influence knowl-edge, attitudes and behaviors related to painmanagement among OA.

Methods. A case-based, low-literacy, bilingual videowas developed to educate OA on medication side ef-fects, address addiction fears, and encourage OA todiscuss pain with their clinicians/families. Educationalintervention included a short presentation by a health-care professional followed by video. Interventiontargeted OA at six senior care centers. Bilingual pre-and post-questionnaires were administered.Results. N¼114, mean age 76. 85 (73%) female and31 (27%) male. 29% OA stated that they ‘‘worry’’about taking pain medications, with 8% of thosewho responded specifically stating they would be con-cerned regarding addiction. When comparing pre-/post- survey results, 40% positively shifted frominitially answering they would be worried regardingaddiction to pain medications (56.3%) to after theintervention answering they would worry lessregarding addiction (16.8%) (p<0.001). 48.3% OAalso initially stated it would be easy to discuss painwith clinicians, and this number increased to 73.3%OA answering after the intervention that they wouldfeel comfortable discussing their pain symptoms withclinicians (p<0.0014).Conclusion. This pilot study demonstrated that pa-tient-centered educational interventions can empowerOA to discuss pain-related concerns with their clini-cians as demonstrated by the positive shift in responsewhen OA were asked if they would feel comfortablediscussing their symptoms. This intervention also alle-viated fears of OA regarding pain medication side ef-fects, such as addiction.Implications for Research, Policy orPractice. Future interventions are needed to developvalidated questionnaires regarding pain and painmedication effects to encourage OA to have theirpain addressed early and with their physicians.

Patient-Controlled Analgesia for Cancer-RelatedPain: Clinical Predictors of Patient Outcomes(S785)Emily Martin, MD, University of California, San Diego,San Diego, CA. Madison Sharp, MS, University of Cal-ifornia, San Diego Moores Cancer Center, La Jolla,CA. Eric Roeland, MD FAAHPM, University of SanDiego Moores Cancer Center, La Jolla, CA. CarolynRevta, MPH, University of California Moores CancerCenter, San Diego, CA. Heidi Yeung, MD, Universityof California, San Diego, San Diego, CA.

Objectives� Review current evidence for patient-controlledanalgesia (PCA) use in the inpatient setting.

� Define characteristics in patients admitted withcancer-related pain on PCAs, and describe therelationship between these variables and patternsof PCA use and hospitalization.


� Describe future research that will help to refinePCA use in cancer-related pain.

Original Research Background. Patient-controlledanalgesia (PCA) is widely used in the inpatient settingfor uncontrolled pain, and it is well studied in thepost-operative setting. Data regarding its use for pa-tients admitted with cancer-related pain, however, islimited.

Research Objectives. The purpose of this study is todefine the patterns of PCA use and related outcomesin a retrospective cohort of patients admitted to thehospital with cancer-related pain.

Methods. We identified 90 patients admitted to a sin-gle academic center with a cancer diagnosis whoreceived PCA for non-surgical, cancer-related painand who survived to discharge between January 2013and January 2014. Data including patient demo-graphics, type of cancer and pain, time from admis-sion to PCA initiation to PCA discontinuation todischarge, opioid-specific adverse events, and 30-dayreadmission rates for pain were collected. Univariableand multivariable linear regression models were usedto look for any association between patient and clin-ical variables with PCA duration. Logistic regressionmodels were used to evaluate the relationship betweenpatient and clinical variables and 30-day readmissionrates.

Results. The median length of hospitalization was10.15 days with a median PCA duration of 4.40 days.Hematologic tumors were associated with longerPCA use (p¼0.0001), as was younger age (p¼0.032).There was a borderline-significant trend towardsdecreased 30-day readmission rates with longer PCAuse (p¼0.054). No correlation was found between30-day readmission and any covariate studied,including palliative care consult, sex, pain type, cancertype (solid vs. hematologic), age, or time from discon-tinuation of PCA to discharge.

Conclusion. This study found that, in patientsadmitted with cancer-related pain, there is longerPCA use in younger patients and in patients with he-matologic malignancies, with a trend towardsdecreased 30-day readmission rates in those withlonger PCA use.

Implications for Research, Policy orPractice. Future research is needed to identify sub-sets of oncology patients that will benefit the mostfrom PCA use.

The Acceptability to African Americans of aStructured Conversation Guide to ImproveAdvance Care Planning (ACP) in the Setting ofCancer: A Tiered Focus Group Study (S786)Justin Sanders, MD MSC, Dana-Farber Cancer Insti-tute, Boston, MA. Katherine Sterba, PhD MPH,

Medical University of South Carolina, Charleston,SC. Dee Ford, MD, Medical University of South Car-olina, Charleston, SC. Susan Block, MD FAAHPM,Dana-Farber Cancer Institute, Boston, MA.

Objectives� Understand disparities between African Americanand European Americans in receipt of high-qual-ity end-of-life care and in advance care planning.

� Incorporate evidence-based communication stra-tegies for addressing disparities in advance careplanning with African Americans.

Original Research Background. African Americansare likely to receive worse end-of-life (EOL) care andare less likely to participate in advance care planning(ACP) and enroll in hospice than European Ameri-cans. Literature points to the impact of religion,mistrust, preferences for life-sustaining treatment,family-decision making styles, and health literacy.Early and effective ACP conversations are associatedwith improved EOL outcomes, including more goal-concordant care. Preliminary data suggests that aserious illness conversation guide (‘‘guide’’)embedded in a systems based approach to improvingillness care leads to more, better, and earlier conversa-tions about patient goals and priorities in a predomi-nantly white and middle class population of cancerpatients. We hypothesized that African American par-ticipants would suggest or approve of modificationsto the guide that addressed religion and spirituality.

Research Objectives. To determine acceptability ofa structured conversation guide to improve ACPamong African Americans.

Methods. In this first phase of a two-phase study toadapt the guide for use in more diverse populations,we conducted a series of focus groups with expertsin disparities and the care of seriously ill African Amer-icans, African American church members, and seri-ously ill patients and their caregivers to identifybarriers to ACP and to determine the acceptabilityof a guide to improve the timeliness and quality ofconversations to identify goals and priorities for care.We used template analysis to code anticipated andnovel themes.

Results. Participants endorsed multi-level structuralbarriers to ACP, some of which may be addressedthrough modification of the guide. Participants foundthe guide to be acceptable when it included a questionthat allowed space for discussion of coping mecha-nisms, including faith and family.

Conclusion. African American participants in ourfocus group study found acceptable the use of aserious illness conversation guide to identify patientgoals and priorities.

Implications for Research, Policy orPractice. These results support the use of a


structured communication tool to improve ACP indiverse populations.

Impact of Creating Legacy Teaching Videos onWell-Being of Advanced Cancer Patients (S787)Christina Fitch, DO MPH, University of MassachusettsMedical Center, Worcester, MA. Jennifer Tjia, MD,University of Massachusetts Memorial Medical Center,Worcester, MA. Alex Doering, BA, University of Massa-chusetts Medical School, Worcester, MA. Suzana Ma-kowski, MD, University of Massachusetts MemorialMedical Center, Worcester, MA. Amy Wachholtz,MDiv PhD MS, University of Massachusetts MedicalSchool, Worcester, MA.

Objectives� Outline the psychological benefits of life story re-view through legacy teaching videos.

� Define ways future healthcare providers couldfind insights and learning from the lived experi-ences of cancer patients.

Original Research Background. The beneficial ef-fects of life story review on the quality of life for adultswith advanced illness is well described, including thecreation of legacy videos for family gifting. It is un-known whether creating legacy videos with the intentof teaching future healthcare professionals about the‘‘cancer patient’’ experience is beneficial or meaning-ful to patients.Research Objectives. This study aims to describe theimpact of creating legacy teaching videos on the well-being of patients with advanced cancer.Methods. Adults were recruited from the outpatientand inpatient oncology and palliative medicine ser-vices of an academic medical center. Eligibilityincluded a diagnosis of an advanced cancer, ECOGscore of 0-3, English speaking, and without active psy-chosis. Patients underwent, in person, video recordedinterviews that followed a semi-structured interviewguide that addressed the lived experience of being a‘‘cancer patient,’’ coping, and how the patient thoughtclinicians could provide better care to future patients.We measured the Functional Assessment of CancerTherapy - General (FACT-G), Hospital Anxiety andDepression Scale (HADS), Patient Dignity Inventory(PDI), and Distress Thermometer.Results. Of 18 patients already referred, 6 completedthe interview and the follow-up visit. Patients reportedthat they ‘‘really enjoyed the experience,’’ and ‘‘it hadhelped them process’’ their cancer experience. A com-mon theme was the patient’s strong desire to helpothers by sharing their story. Mean baseline scoresare: FACT-G ¼ 74.4 (SD 29.43); HADS-A 5.7 (SD4.76); HADS-D 5.7 (SD 4.23); PDI 44.0 (SD 22.99);Distress Thermometer 2.2 (SD 2.64). Mean follow-upscores are: FACT-G ¼ 77.4 (SD 23.53); HADS-A 4.8

(SD 3.92); HADS-D 5.0 (SD 4.10); PDI 41.8 (SD18.78); Distress Thermometer 1.8 (SD 2.64).Conclusion. Advanced cancer patients report thatparticipation in an educationally-oriented legacy videoproject is enjoyable and potentially beneficial.Implications for Research, Policy orPractice. Cancer patient legacy making and humanis-tic medical education can be linked for mutual bene-fit.

Exploring the Emotional, Psychosocial andPhysical Effects of a Community-Based ExerciseProgram for Cancer Survivors (S788)Beth Kollas, PhD, YMCA of Central Florida, Orlando,FL. Chad Kollas, MD FACP FCLM FAAHPM, Univer-sity of Florida Health Cancer Center at OrlandoHealth, Orlando, FL.

Objectives� Identify the physical and psychosocial benefits ofexercise for cancer survivors.

� Understand survivor exercise guidelines andexplore how to discuss these with cancer patients.

� Identify the key elements of cancer survivor exer-cise programs.

Original Research Background. As survival rates formany cancers continue to increase, there is a growingdemand to meet the unique needs of cancer survivorswhen their cancer treatments result in a loss of phys-ical ability, limitation in activities of daily living, andnegative impact of social and emotional function.Research Objectives. To assess the psychosocial andemotional effects of a community-based exercise pro-gram for cancer survivors as well as to ensure similarphysical benefits when delivered by lay workers.Methods. We qualitatively and quantitatively studiedthe impact of the LiveSTRONG at the YMCA exerciseprogram over the course of 24 sessions using a seriesof functional assessments to measure participants’ aer-obic fitness, strength, and flexibility and balance at thebeginning and end of the program. Additionally, par-ticipants completed the Patient-Reported OutcomesMeasurement Information System 29-item Health Pro-file (PROMIS-29), which measures health status forphysical, mental, and social well-being.Results. In 2014, 117 patients participated in theLiveSTRONG at the YMCA program in Central Flor-ida, with an average age of 59.5 years (75% female,87% breast cancer). Results of this cohort’s functionalassessments showed an increase in aerobic function(22.7%), flexibility (13.3%), balance (39.7%), andstrength (45%), which is similar to other studies. Addi-tionally, results from PROMIS-29 reflected significantimprovements in several psychosocial areas, includinganxiety (60%), satisfaction with social role (56%),sleep (40%) and depression (28%).


Conclusion. These results suggest that a community-based cancer survivorship program can not only effec-tively engage survivors in safe physical activity, but canalso build relationships and improve quality of life.Effective, affordable, and accessible programs pro-vided by community-based organizations such as theYMCA are key to filling the clinic-to-community gapthat exists for this vulnerable population.

Implications for Research, Policy orPractice. With the growing number of cancer survi-vors, it is imperative to re-examine payment modelsfor treating cancer patients to include survivorshipprograms in community-based settings.

The Emergency Department-Generated Plan-of-Care Consultation: Earlier Access to PalliativeCare and Reduced Risk of Inpatient Death(S789)Jun Onitsuka, MD, Oregon Health Science University,Portland, OR. Daniel Fischberg, MD PhD FAAHPM,The Queen’s Medical Center, Honolulu, HI. IlanBernstein, MD, The Queen’s Medical Center, Honolu-lu, HI.

Objectives� Evaluate the effect that early plan-of-care consul-tations originating in the emergency departmenthave on subsequent hospital mortality riskcompared with referrals placed later in anadmission.

� Evaluate the effect that early plan-of-care consul-tations originating in the emergency departmenthave on subsequent hospital length of staycompared with referrals placed later in anadmission.

Original Research Background. Compared withpalliative care consultations placed later during hospi-tal admissions, early referrals originating in the emer-gency department may influence risk of hospitalmortality.

Research Objectives. We aimed to evaluate whetherpalliative care consultations placed to assist with a planof care originating in the emergency departmentinfluenced risk of hospital mortality compared with re-ferrals made later in the inpatient setting.

Methods. A retrospective analysis was performed us-ing data collected between January 1, 2010 andDecember 31, 2014 by the palliative care team in a533-bed teaching hospital. We logged the number ofplan of care (POC) referrals initiated in the emer-gency department (ED) and in the inpatient setting.Inpatient mortality, hospital length of stay (HLOS),code status changes made by the palliative care teamto DNR, and hospice disposition were recorded.

Results. 1379 and 104 plan-of-care consultations wereplaced by inpatient and ED referrers, respectively.

Hospice disposition and code status adjustment ratesdid not differ significantly between the groups. Thehospital death rate was significantly lower in the ED-referred group (18% vs. 30%, p<0.013). AverageHLOS was reduced amongst patients who had plan-of-care consultations placed in the ED comparedwith those whose referrals were placed in the inpatientsetting (6.3 days vs. 13.66 days, respectively.p<0.0001). Mean time from hospital presentation toPOC consultation was 7.43 days in the inpatient popu-lation compared with 0.59 days amongst ED-referredpatients (p<0.0001).

Conclusion. Plan-of-care consults originating in theED resulted in a significantly reduced risk of in-hospi-tal death compared with inpatient referrals. Averagehospital length of stay in the ED population wasreduced as well, which could suggest a mechanismfor a reduction in the hospital mortality rate.

Implications for Research, Policy orPractice. Initiatives to generate earlier palliativecare consultations may reduce hospital mortality riskamongst patients admitted with advanced illnesses.

Systematic Advance Care Planning in the NursingHome: Preliminary Outcomes from theOPTIMISTIC (Optimizing Patient Transfers,Impacting Medical Quality, and ImprovingSymptoms: Transforming Institutional Care)Demonstration Project (S790)Susan Hickman, PhD, Indiana University School ofNursing, Indianapolis, IN. Kathleen Unroe, MD, Indi-ana University Health Inc., Indianapolis, IN. MaryErsek, FPCNRN, University of Pennsylvania, Philadel-phia, PA. Bryce Buente, MPH, Regenstrief Institute,Indianapolis, IN. Greg Sachs, MD, Indiana UniversitySchool of Medicine, Indianapolis, IN.

Objectives� Discuss the relationship between advance careplanning and the hospitalization of nursing facil-ity residents.

� Describe successes and challenges to systematicadvance care planning in the nursing facilitysetting.

Original Research Background. Advance care plan-ning (ACP) has promise as an important strategy toreduce potentially avoidable hospitalizations ofnursing facility patients by eliciting goals and prefer-ences to guide treatment decisions.

Research Objectives. To assess the status of ACP im-plementation for long-stay nursing facility patientscurrently enrolled in a Centers for Medicare andMedicaid-funded demonstration project approxi-mately halfway through the four-year project.

Methods. Participants (n¼1516) are long-stay pa-tients at 19 nursing homes. Nurse interventionists (n


¼ 18 RNs), who are certified Respecting Choices LastSteps POLST (Physician Orders for Life-SustainingTreatment), are embedded full time in the nursing fa-cilities and engage in ACP discussions as a corefunction.Results. About half (44% or 665/1516) of the pa-tients had engaged in ACP either with the RN orsomeone else. The most common reason for no ACPconversation was that the RN had not gotten to theresident yet (61% or 521/851). ACP discussions withRNs resulted in a change in orders 74% of the time.About a third (30% or 462/1516) of the patientshad a POLST form, and most (77% or 356/462)were prepared by the project RN. A majority of POLSTforms contained orders for Do Not Resuscitate (84%)and comfort measures/hospitalize for comfort only(54%).Conclusion. Findings suggest that systematic ACP inthe nursing home setting is feasible and often resultsin a change of orders to reflect resident/surrogatepreferences. However, competing demands createchallenges in the early stages of implementation.Structured systems are needed to ensure each residentis provided with the opportunity to engage in ACPconversations.Implications for Research, Policy orPractice. Systematic, comprehensive ACP is achiev-able in the nursing home, but it requires a championwho has dedicated time to engage in conversationsand has clear support to prioritize this activity.

Comparison of Symptoms in Patients with LungCancer and Hepatocellular Cancer Referred forPalliative Care at a VA Medical Center (S791)David Klein, DO, Hospice of New York, Queens, NY.Daniel Dinardo, DO, St. John’s Episcopal Hospital,Merrick, NY. Stephanie Hwa, NP, James J. Peters VAMedical Center, New York, NY. Jennifer Superson,MSW, James J. Peters VA Medical Center, Brooklyn,NY. Victor Chang, MD, VA New Jersey Health Care Sys-tem, East Orange, NJ. Ellen Olson, MD, James J. Pe-ters Veterans Administration Medical Center, Bronx,NY.

Objectives� Compare symptom prevalence in lung cancer andliver cancer patients.

� Compare symptom interventions for clinicalproblems in lung cancer and liver cancer patients.

Original Research Background. Little is knownabout symptoms in hepatocellular cancer (liver can-cer), although it is a leading cause of cancer deathsworldwide. We compared symptoms in hepatocellularcancer patient with a more well-known group: lungcancer patients.

Research Objectives. To determine if there is a dif-ference in symptom profile and management betweenpatients with liver cancer and lung cancer.Methods. Clinical data were abstracted from charts ofinpatients with hepatocellular carcinoma or lung can-cer who were seen by the Palliative Care Consult Ser-vice from 2008 to 2012 (n¼80) at the James J. PetersVA Medical Center (VAMC). Patients were matchedby age and year of consultation. Symptoms were as-sessed at intake with the Condensed Memorial Symp-tom Assessment Scale. Frequency of symptominterventions for pain, ascites, pleural effusions, andencephalopathy were compared.Results. There were 80 patients, 40 with lung cancerand 40 with liver cancer. Median KPS was 50% for bothgroups, and survival from palliative care consultationwas 40 days for both groups. Symptom ratings were ob-tained from 33 patients with lung cancer and 34 pa-tients with liver cancer. Both groups had 90%prevalence of symptoms. Weight loss (80% in lungvs. 44% in liver cancer patients, p < .004) and short-ness of breath (67% in lung cancer patients vs. 26%in liver cancer patients, p<.001) were more prevalentin lung cancer patients. The median number of symp-toms was five for both groups of patients, with a rangeof one to 10, and estimates for summary physicalsymptom distress and psychological distress scoreswere similar. Symptom interventions for ascites weremore frequent for the liver cancer patients (57% vs.16% for lung cancer patients, p< .001).Conclusion. Patients with hepatocellular cancer havea different symptom profile when compared to lungcancer patients, and they require more interventionsfor ascites .Implications for Research, Policy orPractice. These data will aid in developing palliativecare services for patients with hepatocellular cancer.

Dosing of Analgesics for Patients with LiverCancer or Lung Cancer (S792)Milena Monskaya, PharmD JJPMC, Brooklyn, NY.Jennifer Pruskowski, PharmD, University of PittsburghSchool of Pharmacy, Pittsburgh, PA. Yleana Garcia,PharmD, Kaweah Delta Health Care District, Visalia,CA. Victor Chang, MD, Veterans Administration NewJersey Health Care System, East Orange, NJ. EllenOlson, MD, James J. Peters Veterans AdministrationMedical Center, Bronx, NY.

Objectives� Describe prescription of analgesics in patientswith liver or lung cancer.

� Describe prescription of analgesics in patientswith hepatic impairment.

Original Research Background. Analgesic adminis-tration in patients diagnosed with hepatocellular


carcinoma (liver cancer) can be difficult because ofthe paucity of evidence-based guideline recommenda-tions for dosing opioids in patients with hepaticimpairment. We hypothesized that dosage of acet-aminophen and of opioids might differ for liver can-cer patients compared to lung cancer patients seenat a VA medical center.

Research Objectives. To compare prescribing ofacetaminophen and of morphine in patients with liveror lung cancer seen by a palliative care service at a VAmedical center.

Methods. We reviewed the charts of 40 patients withlung cancer and 40 patients with liver cancer whowere referred between 2008 and 2012 and werematched by age and year of referral. Charts wereabstracted for symptoms, serum creatinine, total bili-rubin, acetaminophen doses (prescribed andreceived), and oral morphine equivalents (prescribedand received) near and at the end of life.

Results. The prevalence (55%) and distress related topain were similar in both groups of patients. Bilirubinlevels were higher (3.0 mg in liver cancer vs. 0.92 mg,p<0.001) and albumin levels were lower (3.09 g/dl inliver cancer patients vs. 3.59 g/dl), and creatinineclearance was similar at 87 ml/min. Acetaminophen(APAP) prescriptions were written for three (7%) livercancer patients and 14 (35%) lung cancer patients (p.0026). Opioid prescriptions were written for 18(45%) liver patients and 25 (63%) lung cancer pa-tients (NS). The maximum prescribed dose of APAPwas 162 mg (1950-2600) for liver patients and 942mg (975-3900) for lung patients (p .004). Median dailydoses of morphine were 45 mg/ for liver patients and49 mg for lung patients. Only half of the lung cancerand liver cancer patients received the prescribedanalgesics.

Conclusion. Differences were found in the prescrip-tion and dosage of acetaminophen and the receiptof analgesics.

Implications for Research, Policy orPractice. These findings should be confirmed inother populations.

Impact of Neuropathic Pain Treatments onOpioid Use and Pain Level in Gastrointestinaland Genitourinary Malignancy (S793)Zachary Binney, MPH, Emory University - RollinsSchool of Public Health, Atlanta, GA. Earl Smith,MD PhD FAAPM, Emory University, Atlanta, GA.

Objectives� Describe the importance of neuropathic pain ingastrointestinal and genitourinary malignancies.

� Evaluate the impact of initiating neuropathic paintreatment on opioid need and pain levels ingastrointestinal and genitourinary malignancies.

Original Research Background. Neuropathic painis common in gastrointestinal (GI) and genitourinary(GU) cancer, yet little is known about the efficacy ofcommon neuropathic pain agents in this population.

Research Objectives. Describe the impact of neuro-pathic agents (gabapentin or pregabalin (G/P)) onpain and opioid use in hospitalized GI and GU cancerpatients.

Methods. We reviewed charts of inpatients with GIand GU cancer at a southeastern academic health sys-tem from January to June 2015. We assessed demo-graphics, G/P use, and dose. We calculated average24-hour pain score (numeric, 0-10) and daily totaloral morphine equivalents at zero, one, three, andfive days from G/P start. We analyzed six tumorgroups: anorectal, gynecologic (cervical, uterine,ovarian), pancreatobiliary, prostate, upper GI (gastric,small intestine), and urinary (bladder, urethra).Opioid use was categorized as unchanged (within5% of pre-G/P level), increased, or decreased.

Results. Of 1286 hospitalizations, 216 (16.8%)received G/P, ranging from 12.2% for prostate to41.1% for anorectal cancer. Of the 216, 59.2%were male. 50.9% were white, and 41.2% were Afri-can American. Mean age was 61.7 years (standarddeviation (SD) 12.6). Mean (range, milligrams)doses at day one for gabapentin and pregabalinwere 570 (0 to 2000 mg) and 129 (0 to 300 mg),respectively. 32.4%, 36.6%, and 46.3% of patientsexhibited decreased opioid use at one, three, andfive days after G/P start. Upper GI (75.0%), pan-creatobiliary (58.5%), and urinary cancers (54.2%)had the strongest decreases at five days. 29.0%,30.2%, and 40.4% experienced at least a 50%reduction in pain at one, three, and five days,respectively.

Conclusion. A plurality of patients exhibited loweropioid requirements five days after starting G/P forneuropathic pain. However, without a control groupwe cannot say G/P caused this reduction.

Implications for Research, Policy orPractice. Concurrent neuropathic agents with opi-oids may improve pain and reduce opioid require-ments in some GI and GU cancer patients.

Retrospective Review of Patient Outcomes AfterPalliative Care Consultation Among PatientsUndergoing Hypothermia Protocol (S794)Priya Pinto, MBBS, Montefiore Medical Center Bronx,Bronx, NY.

Objectives� Understand the role of the palliative care team inpatients undergoing hypothermia protocol.


� Evaluate the impact that the palliative care teamcould have on the care of these patients.

Research Objectives. To describe clinical andhealthcare utilization outcomes for patients who un-derwent hypothermia protocol following cardiac ar-rest and did or did not receive palliative careconsultation.Methods. We identified patients admitted to a criticalcare unit between 2006 and 2012 who had undergonehypothermia protocol in the setting of a cardiac arrest.Results. Reviewed the charts of 62 patients who un-derwent hypothermia protocol following cardiac ar-rest, of which 35 (56%) received a palliative careconsultation. Twenty-one patients (34%) survived, ofwhich only eight (13%) had a good neurologicaloutcome. Twenty-six (74%) of the patients seen bypalliative care died (22 in the hospital, 13 after pallia-tive extubation, four in hospice). Fifteen (56%) ofthose patients without a palliative consultation diedin the hospital, three after palliative extubation;none died in hospice. The mean hospital length ofstay was 16.71 days for patients seen by palliative careand 17.1 days for patients not seen (p¼ 0.90). MeanICU length of stay for patients seen by palliative carewas 11.34 days compared with 12.59 days for patientsnot seen (p 0.55). Among patients who died in thehospital, the mean length of stay was 13.40 days for pa-tients seen by palliative care compared with 8.87 daysfor those not seen (p 0.06). Mean ICU length of stayamong those that died in the hospital was 10.72 daysfor those seen by palliative care compared with 8.73for those not seen(p 0.35).Conclusion. Palliative care consultation for patientswith hypothermia protocol results in increased ratesof deaths on hospice. Palliative care consultationmay be associated with a lower mean ICU and hospitallength of stay, however, the study was underpowered todetect a difference.Implications for Research, Policy orPractice. This is an area of growing interest, andthere would be great value in prospective studies ofpalliative care in these patients.

Parental Perspectives of Communication at theEnd of Life at a Pediatric Oncology Institution(S795)Jennifer Snaman, MD, St. Jude Children’s ResearchHospital, Memphis, TN. Carlos Torres, MS, Universityof Memphis, Memphis, TN. Justin Baker, MDFAAHPM, St. Jude Children’s Hospital, Memphis, TN.

Objectives� Identify important themes related to verbal andnonverbal communication at the end of life as

described by bereaved parents in a focus groupsetting.

� Identify ways in which they may improve theirown practice of communicating with patientsand families at the end of life.

Original Research Background. The interaction ofhealthcare providers and hospital staff with patientsand families at the end of life affects the parental griefexperience. Both verbal and nonverbal communica-tion are key components of this interaction.Research Objectives. To explore the communica-tion between hospital staff members and patientsand families at the time of patients’ health declinenear the end of life.Methods. Twelve bereaved parents participated in afocus group. Semantic content analysis was used toanalyze the transcript.Results. Parents’ responses to the prompt abouttypical ways the medical team communicated yielded109 codes, which were grouped into 12 themes. Themost common theme was ‘‘patient inclusion’’ and‘‘explanation of medical plan,’’ used in 17% of re-sponses. Responses to the prompt about positiveand negative aspects of communication generated208 codes, yielding 15 different themes that weresubdivided into positive (109 codes) or negative(94 codes) communication. The most commontheme about positive communication was ‘‘the rela-tionship between family and staff’’ (24.8% of re-sponses, 72% of parents). The theme ‘‘negativevariations in care’’ was used most (24% of responses,54% of parents) in describing negativecommunication.Conclusion. This study helps identify techniques thatshould be used by clinicians as they work with childrenwith cancer and their families, particularly includingpatients in treatment decisions, ongoing relationshipbuilding, communicating with caring and empathy, us-ing an interdisciplinary team for additional support,and pairing bad news with a plan of action.Implications for Research, Policy orPractice. These findings suggest that a two-stepapproach to these conversations may be most helpfulto patients and families, similar to an approach thatwas recently outlined for Phase I informed consentdiscussions.

Palliative Care Integration into CardiacTransplant Recipient Care: A Retrospective CaseSeries (S796)Manik Aggarwal, MD MPH, MedStar GeorgetownUniversity Hospitals, Washington, DC. Kathryn


Walker, PharmD BCPS CPE, MedStar Health, Univer-sity of Maryland School of Pharmacy, Baltimore, MD.Renee Holder, PharmD BCPS CPE, MedStarWashington Hospital Center, Washington, DC.Anne Kelemen, MSW, MedStar Washington HospitalCenter, Washington, DC. J. Hunter Groninger, MDFAAHPM, MedStar Washington Hospital Center,Washington, DC.

Objectives� Review morbidity, mortality, and supportive careneeds of cardiac transplant recipients.

� Introduce model of palliative care consultativeservice integrated into a cardiac transplantationprogram.

� Describe findings of retrospective case series ofcardiac transplant recipients receiving palliativecare consultation.

Original Research Background. Cardiac transplan-tation, a life-prolonging therapy available to select pa-tients with advanced heart failure, is associated withsignificant morbidity, mortality, and supportive careneeds. Despite calls for integration of palliative care(PC) services into transplant workup and care, suchpartnerships are extremely rare, and data remainslimited about how such services benefit cardiac trans-plant patients and families. Since January 2015, theMedStar Washington Hospital Center Palliative CareService has provided consultations to transplant pa-tients from the MedStar Heart and Vascular Institute,whose program completes a median of 10 heart trans-plants per year.

Research Objectives. To describe indications for PCconsultation and PC interventions in cardiac trans-plant recipients.

Methods. All cardiac transplant recipients whoreceived PC consultation between January and July2015 were reviewed retrospectively through the elec-tronic health record. Reasons for consultation, painand symptom assessment (on day 0, 2), estimatedprognosis, PC interventions, and disposition werecollected. Descriptive statistics were used to analyzedata.

Results. Sixteen PC consults took place for 10 car-diac transplant recipients (time since transplanta-tion median 10 months; median numberhospitalizations 2.5 over study period). The primaryreason for PC consultation was symptom manage-ment (pain 86%, non-pain symptoms 14%). Fifty-seven percent of the patients had moderate to se-vere (2-3/3) symptoms at presentation. Symptomscores decreased to none to mild (0-1/3) within48 hours of initial consultation in 28% patients.Additional PC interventions included psychologicalcounseling (19%), spiritual care (13%), disease

state education (6%), and medical proxy determi-nation (6%). Most hospitalized patients were dis-charged, but two required end-of-life care duringhospitalizations.Conclusion. In this series, cardiac transplant recipi-ents experienced notable symptom burden, re-sponded well to interventions to treat symptoms, andrequired additional PC interventions.Implications for Research, Policy orPractice. Future research should further describePC consultation’s role and benefit in cardiac trans-plantation.

Parents’ Relationship with Healthcare ProvidersDuring the Child’s Dying Process with Cancer atthe Hospital (S797)Maiara Rodrigues Santos, RN MSN, Federal Univer-sity of S~ao Paulo, S~ao Paulo, Brazil. Maira Misko,RN MSN PhD, Federal University of S~ao Paulo, S~aoPaulo, Brazil. Michelle Baliza, RN, University of S~aoPaulo, S~ao Paulo, Brazil. Regina Bousso, RN MScPhD, Federal University of S~ao Paulo, S~ao Paulo,Brazil.

Objectives� Identify meanings bereaved parents assign to therelationship established with healthcareproviders.

� Identify the elements that help parents andhealthcare providers to establish a secure rela-tionship during the child’s end of life.

Original Research Background. The relationshipestablished between healthcare providers, parentsand children during end-of-life caring is complexand multidimensional. There are still little evidencethat explores how these relationships during thechild’s last hospitalization influence parental adapta-tion after their child’s death.Research Objective. This study aimed to understandthe experience of parents in their relationships withnurses during their children with cancer’s dying pro-cess in the hospital.Methods. The philosophical hermeneutic was usedto conduct the study. Family members were inter-viewed at least six months after their child’s deathfrom cancer in the hospital. For the recruitment, asearch in a pediatric hospital’s obituary helped iden-tify families. Each interview was audiotaped and tran-scribed. For the analysis, units of meaning andclusters were identified, then categories were induc-tively determined and submitted to an interpretationprocess.Results. The most relevant aspects that emerged inparents’ experience regarding the relationship estab-lished with healthcare providers were:


communication, bond, care access, competence,values, and beliefs. The presence of these elements in-fluences the way parents perceive their role while theylive the unexpected experience of losing a child, andthey remain in their memories associated with themeanings attributed for the illness and the loss.Conclusion. These relationships serve as the basis tostrengthen and support the parenting role, and theybecome a remarkable reminder that parents keep asa permanent connection to their deceased child. Byrevisiting these memories, meanings arise thatcontribute to their grieving process.Implications for Research, Policy or Practice. Thequality of parents’ bond formed with the healthcareproviders is a concrete reminder of the child’s lastdays and the illness trajectory, influencing the qualityof their grieving process. Policies in pediatric palliativecare must emphasize directives to enhance the prac-tice of allowing families to maintain the secure bondafter their child’s death, helping to prevent compli-cated grief.

Intervention to Integrate Palliative Care intoTransitional Care for Older Adults: PotentialChallenges Identified by Clinicians (S798)Seiko Izumi, RN PhD, Oregon Health & Science Uni-versity, Portland, OR. Basilia Basin, BS, Oregon Health& Science University, Portland, OR. Judith Baggs, RNPhD FAAN, Oregon Health & Science UniversitySchool of Nursing, Portland, OR.

Objectives� Describe palliative care needs among older adultpatients with chronic conditions who are transi-tioning from hospital to home.

� Identify potential benefits and challenges to inte-grate palliative care into transitional care.

Background. Poorly managed symptoms and lack ofadvance care planning (ACP) for older adults withchronic conditions may lead to unwanted hospital re-admissions and eventual death in the hospital. Inte-gration of palliative care into post-hospitalizationprimary care is a promising strategy to improve carefor this population.Objectives. We conducted a two-phase, formative-evaluation study to assess the feasibility of registerednurses implementing primary palliative care into hos-pital-to-home transitional care. This paper reportsfindings from the first phase. Expert clinicians atthe feasibility study site were interviewed to identifypotential challenges and facilitators of such anintervention.Method. The transitional palliative care (TPC)intervention proposal was developed by combining

transitional care best practices with the palliativecare principles of symptom management and ACP.TPC included a home visit and three months oftelephone follow-up focusing on symptom manage-ment and ACP. The proposed intervention was eval-uated by palliative care, transitional care, andgeriatric care experts (n¼26) in small group inter-views. Data were analyzed using qualitative contentanalysis.Results. All participants agreed it would be benefi-cial to integrate palliative care into the transition pro-cess. Potential challenges the participants identifiedincluded 1) patients with varied chronic conditionshaving diverse needs, 2) overlapping roles of involvedhealthcare providers, and 3) potential conflict withexisting practices. Participants said patients’ needsvary by their bio-psycho-social profile, and diversityin their needs requires the intervention nurses tobe resourceful and knowledgeable about manage-ment of multiple symptoms. Participants expressedconcerns that the intervention might duplicate exist-ing work of healthcare providers or hinder currentpractice.Conclusion and Implications. To meet the diverseneeds of patients and be feasible to implement, themodified TPC was incorporated into an existing tran-sitional care service by health coaches, and interven-tion nurses’ training was augmented to includeprimary palliative care principles.

Understanding the Advance Care Planning Needsof Palliative Care Patients: IdentifyingOpportunities for Improvement (S799)Kara Bischoff, MD, University of California SanFrancisco, San Francisco, CA. Shayna McElveny,BA, University of California San Francisco, San Fran-cisco, CA. David O’Riordan, MPH PhD, University ofCalifornia San Francisco, San Francisco, CA. AshleyBragg, BS, University of California San Francisco,San Francisco, CA. Steven Pantilat, MD FAAHPMMHM, University of California San Francisco, SanFrancisco, CA.

Objectives� Understand the advance care planning needs ofinpatients referred to palliative care services.

� Describe the advance care planning activitiescurrently completed by inpatient palliative teams.

� Consider opportunities to improve the advancecare planning provided by inpatient palliativeteams.

Original Research Background. Advanced careplanning (ACP) is a critical function of PC teams,but it has not been well characterized.


Research Objectives. Describe the activities that PCteams undertake to meet the ACP needs of patients.Methods. Twenty-four PC teams in the PC QualityNetwork (PCQN) entered data on 9515 patient en-counters between July 1, 2014 and June 30, 2015. Weexamined patient characteristics associated with ACPand activities performed by PC teams.Results. Overall, 72% of patients (6869/9515)screened positive for ACP needs, and PC teams pro-vided ACP for 95.3% of these patients (6545). Patientsreferred for ACP were more likely to have cancer(32.2%, p¼0.0001) than cardiovascular (13.1%), pul-monary (11.6%), or neurologic (10.7%) disease. Pa-tients referred for ACP had an average of 1.2 familymeetings with the PC team, compared to one meetingfor other patients. Forty-two percent of patients(3962) were DNR/DNI at the time of PC consultation,which increased to 64% by hospital discharge ( 16.8%increase). Sixteen percent of patients (1583) had anadvanced directive (AD) available at the time of PCconsultation, and PC teams completed an AD foronly 3% of patients (n¼265). Eleven percent of pa-tients (n¼1,067) had a physician order for life-sustain-ing treatment (POLST) at the time of PCconsultation, and PC teams completed a POLST for15% of patients (n¼1407). Among patients whowere DNR/DNI or partial code upon hospitaldischarge, 23% left with a completed AD and 38%with a completed POLST.Conclusion. Palliative care teams provide ACP forthe majority of the patients they see. After PC consul-tation, significantly more patients choose DNR/DNIstatus. However, the minority of patients leave the hos-pital with a completed AD or POLST.Implications for Research, Policy orPractice. Quality improvement efforts should focuson increasing the use of ADs and POLSTs to docu-ment patients’ preferences.

The End-of-Life Experience of Patients with CysticFibrosis and the Role of Pediatric Palliative CareConsultation (S800)Elliot Rabinowitz, MD, Dana-Farber Cancer Institute,Boston, MA. Gregory Sawicki, MD MPH, Boston Chil-dren’s Hospital, Boston, MA. Christina Ullrich, MDMPH FAAHPM, Dana-Farber Cancer Institute, Boston,MA.

Objectives� Describe patterns of medical care provided to pa-tients with cystic fibrosis (CF) around the end oflife.

� Explore the roles a pediatric palliative careconsultation service serves for patients with CFwho ultimately die from their disease.

Original Research Background. While major ad-vances have been made in the care of patients withcystic fibrosis (CF), it remains a life-limiting diseaseassociated with significant morbidity. Little is knownabout the patterns of end-of-life (EOL) care for thispopulation and the role pediatric palliative careconsultation can serve.

Research Objectives. To characterize EOL care forpatients with CF who received pediatric palliativecare consultation since the inception of the PediatricAdvanced Care Team (PACT) at Boston Children’sHospital (BCH).

Methods. We identified patients, age $5 years,who died of CF-related disease between 2009 and2014. Patient, clinical, and PACT consultationcharacteristics were abstracted from the medicalrecord.

Results. Fourteen patients with CF who died wereidentified, 57% female; mean age at death was 20.6years (range 14.8 to 42.4 years). Most (86%) receiveda PACT consult. Median time between PACT consultand death was 152 days (range 34 days to 7.4 years).Content of PACT consultations most commonlyincluded symptom management, goals of care,advance care planning, and psychosocial support.Among all who died, (93%) died in the ICU; 86%had a tracheostomy or were intubated, and 100%received non-invasive or mechanical ventilation lead-ing up to death. Seven patients who died in the hospi-tal (54%) had resuscitation status orders documenteda median of 9.1 days prior to death (range 0.4 to 39.1days).

Conclusion. The majority of patients with CF whodied received formal pediatric palliative care consulta-tion, often well before death. Most patients alsoreceived intensive life-sustaining interventions imme-diately prior to death.

Implications for Research, Policy orPractice. There appears to be a role for palliativecare consultation to help foster communication atthe EOL for patients with CF. Further exploringthe role and timing of palliative care consultationfor patients with CF may help healthcare providersidentify areas of improvement in the assessmentand implementation of their patients’ goals ofcare.
