Vol. 53 No. 2 February 2017 Journal of Pain and Symptom Management 305

The Annual Assembly of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association: Education Schedule With Abstracts February 22-25, 2017 Phoenix, AZ

Wednesday, February 22 Make a recommendation about the treatment plan that best meets the patient’s values. 8ame5pm As a palliative care consultant from any professional background, discussing goals of therapy when things AAHPM & HPNA Preconference Workshops are not going well is the most common reason for an inpatient consult. Discussing goals of care is difficult Hospice Medical Director Update and Exam because it requires the consultant to accomplish a num- Prep (P01) ber of interrelated, emotional tasks in a short period of Ronald J. Crossno, MD FAAFP FAAHPM, Kindred time: deliver bad news, assess what is important to the pa- Healthcare, Rockdale, TX. Kathleen Faulkner, MD tient, and make a recommendation about how to best FAAHPM, Good Shepherd Community Care, Newton, proceed. Using a mix of short didactic talks and experi- MA. Edward W. Martin, MD MPH HMDC FACP ential practice, this workshop will help participants FAAHPM, Home & Hospice Care of Rhode Island, develop a toolkit of skills useful for handling these diffi- Cranston, RI. Shaida Talebreza, MD HMDC FAAHPM, cult conversations. This workshop will be unique in that University of Utah Health Care, Salt Lake City, UT. learning will occur predominantly in small groups (one faculty member : eight to ten participants) to allow par- Objectives ticipants to practice the skills, observe others, and give Employ the clinical, regulatory, leadership, and feedback. The groups will be multidisciplinary,led by fac- administrative skills and ethical knowledge ulty with experience in facilitation, and teach skills required in the role of hospice medical director. appropriate for all palliative care clinicians. Describe the hospice medical director’s role on the interdisciplinary care team and within the 2017 AAHPM Fellowship Directors hospice organization. Program: Building a Community of Analyze regulatory issues affecting the hospice Educators (P04) medical director and find strategies to fulfill these Jane deLima Thomas, MD FAAHPM, Harvard Medical requirements. School, Dana-Farber Cancer Institute, Boston, MA. Join peers and national experts to explore and further Anthony L. Back, MD, University of Washington develop the skills needed to successfully navigate to- School of Medicine, Fred Hutchinson Cancer day’s hospice environment. This intensive review will Research Center, Seattle, WA. Jillian Gustin, MD, serve as part of your preparation for the Hospice Med- Ohio State University Wexner Medical Center, Colum- ical Director Certification Board exam and is based on bus, OH. Vicki A. Jackson, MD MPH FAAHPM, Har- the exam blueprint (www.hmdcb.org). The workshop vard Medical School, Massachusetts General also serves as a great orientation for those new to Hospital, Boston, MA. Juliet Jacobsen, MD DPH, Har- the hospice field or as a critical update for all hospice vard Medical School, Massachusetts General Hospital, practitioners and managers. Boston, MA. Lindy H. Landzaat, DO, University of d Kansas Medical Center, Kansas City, KS. Stacie K. Lev- Addressing Goals of Care VitalTalk: ine, MD FAAHPM, The University of Chicago, Chica- Intensive Small Group Training (P02) go, IL. Vanessa Neri, LCSW, VA Palo Alto Health Robert M. Arnold, MD FAAHPM, University of Pitts- Care System, Palo Alto, CA. Vyjeyanthi Periyakoil, burgh, Pittsburgh, PA. Anthony Back, MD, University MD, Stanford University School of Medicine, VA of Washington, Seattle, WA. James Tulsky, MD FACP Palo Alto Health Care System, Stanford, CA. Christian FAAHPM, Dana-Farber Cancer Institute, Boston, MA. Nicole Smith, MPA, The University of Alabama at Bir- Objectives mingham, Birmingham, AL. Respond empathetically to the patient’s expres- Objectives sion of emotion. Identify and exchange funding strategies for Elicit details about the patient’s values. fellowship programs. 306 Schedule With Abstracts Vol. 53 No. 2 February 2017

Become familiar with current work on palliative nursing roles such as nursing assistant, licensed voca- care Curricular Milestones and provide feedback tional/practical nurse, registered nurse, and advanced and input for further development. practice registered nurse. Many organizations have Design approaches for maximizing effectiveness focused time and resources to enhance leadership skills in using interprofessional faculty and in teaching in their staff. These initiatives usually focus on dedi- interprofessional learners. cated nurse leadership positions, such as administra- Develop resiliency curricula for fellows and faculty. tors, managers, directors, or executives. However, The fellowship directors program will provide partici- leadership extends beyond these roles. Nurses with pants with the opportunity to learn about the latest ad- higher levels of motivation lead in many areas besides vances in specialty-level palliative care education, to a designated leadership position. Leadership in pallia- engage in shaping the educational standards that define tive care is characterized by leading others with a clear the field, and to develop connections with other pallia- vision of palliative care initiatives, motivating and tive care educators. Four main topics will be covered inspiring others to achieve excellence in care, positively this year: finding sources of funding for fellowship pro- relating to others to create healthy work environments, grams; vetting the palliative care curricular milestones; and changing the behavior of others to work collabora- maximizing the interprofessional aspect of palliative tively in palliative care (Speck 2006). These leadership care training programs for both faculty and fellows; qualities may be attained by any nurse at any level and developing resiliency curricula for faculty and fel- from the bedside nurse, the nurse group leader or orga- lows. In addition, there will be shorter discussions about nizer, to the nurse in a designated leadership position. some of the more administrative aspects of fellowship The skills of these nurse leaders focus on a broad view program management, such as the Match, activities of of nursing and the ability to respond to change proac- the Residency Review Committee (RRC), and changes tively, rather than reactively, in anticipating the future in fellowship program start dates in other specialties. landscape (Wolf 2012). More specifically, the nurse A major aim of this year’s program is to create and leader must first assess their personal leadership capa- enhance relationships between participants. To that end, bilities prior to moving towards team development every session will have interactive portions designed to in- and competence. Through didactic, role play, and inter- crease collaboration and build community, with the hope active media, this session will articulate the value of that those connections can continue to provide opportu- palliative nursing leadership, describe the characteris- nities for collaboration and support throughout the year. tics of leaders, explore leadership of nurses at all levels of nursing practice, across the spectrum of nursing including clinical, management, education, research, 8ame5:30 pm and policy, and delineate necessary skills of the pallia- tive nurse leader. Palliative Nursing Leadership Intensive (P05) Ò The Shifting Sands of Palliative Care: Constance Dahlin, MSN ANP-BC ACHPN FPCN Maximizing Clinical, Economic and FAAN, Hospice and Palliative Nurses Association, Ò Humanistic Outcomes Across the Continuum Pittsburgh, PA. Julie Tanner, BSN RN CHPN , Hos- of Care (P06) pice and Palliative Nurses Association, Pittsburgh, Mary Lynn McPherson, PharmD MA BCPS CPE, Uni- PA. Patrick Coyne, MSN ACNS-BC ACHPN FPCN versity of Maryland, Baltimore, MD. Diane E. Meier, FAAN, Medical University of South Carolina, South MD FACP FAAHPM, Icahn School of Medicine at Carolina, SC. Mount Sinai, New York, NY. Kathryn A. Walker, Objectives PharmD BCPS CPE, MedStar Union Memorial Hospi- Differentiate essential nursing leadership tal, Baltimore, MD. Joanne G. Kuntz, MD, Emory qualities. Healthcare, Atlanta, GA. Margaret L. Campbell, PhD Apply 5 areas of palliative nursing leadership RN FPCN, Wayne State University, Detroit, MI. Chris- throughout workforce venues. topher D. Kearney, MD, MedStar Palliative Care, Balti- Develop an individualized leadership competency more, MD. Vincent Vanston, MD HMDC FAAHPM, plan to maximize knowledge, transfer and Cooper University Hospital Palliative Medicine, Moor- application. estown, NJ. Balu Natarajan, MD DC HMDC, Seasons Leadership within palliative nursing is not defined or Hospice & Palliative Care, Chicago, IL. Martha L. grounded by level of nursing practice nor education Twaddle, MD HMDC FACP FAAHPM, JourneyCare, but rather on qualities. Leadership in hospice and palli- Glenview, IL. Joanne Reifsnyder, PhD ACHPNÒ, Gen- ative nurses is present throughout the spectrum of esis HealthCare, Rehoboth Beach, DE. Joan K. Vol. 53 No. 2 February 2017 Schedule With Abstracts 307

Harrold, MD MPH FACP FAAHPM, Hospice & Com- through specialty hospice and palliative advanced regis- munity Care, Lancaster, PA. tered nursing certification. This one-day provider- Objectives directed, provider-paced live intensive course is de- Analyze the continuum of palliative care venues that signed to assist with preparation for the advanced hos- are available to patients with an advanced illness. pice and palliative nurse certification exam through Differentiate strategies to optimize clinical, hu- didactic course presentation with active learner engage- manistic and economic outcomes throughout ment, case study examinations, practice exam ques- the palliative care continuum of care. tions and self-check/reflection to highlight self- identifying topics that require further preparation Given an actual or simulated case of a patient with Ò and study in advance of sitting for the ACHPN exam- an advanced illness, apply strategies to facilitate a Ò seamless transition in palliative care. ination. The ACHPN Review Course provides a review This highly engaging full-day preconference will take of the content areas based upon the Hospice and Palli- learners on a journey that spans the entire continuum ative Credentialing Center (HPCC) detailed test con- of palliative care. We will follow complex patients who tent outline. The educational content may also be receive palliative care from the Emergency Depart- used to increase the hospice and palliative advanced ment, the Intensive Care Unit, hospital, long-term registered nurse’s knowledge of palliative nursing. care, outpatient palliative care, home-based hospice Our HPNA faculty are national subject matter experts and inpatient hospice. Participants will learn strategies with career experience in hospice/palliative care and to maximize clinical, economic and humanistic (quality certified by the Hospice and Palliative Credentialing Center in the specialty of Hospice and Palliative Care. of life) palliative care outcomes in each practice setting. Ò Clinical strategies will include both discussion of phar- ACHPN Certification Review course participants macologic and non-pharmacologic interventions. require the following adjuvant materials: Core Curricu- Data regarding cost effectiveness for each practice lum for the Advanced Practice Hospice and Palliative Regis- setting will be discussed (where available), and other tered Nurse, 2nd edition (order online from the HPNA strategies that aim to maximize quality of life will be dis- Shop) and the Hospice and Palliative Credentialing cussed as well. For more traditional settings of hospice Center ACHPN Candidate Handbook (download and and palliative care, participants will learn about print for free at http://hpcc.advancingexpertcare. emerging practice trends. Participants will also gain org/competence/aprn-achpn/). The participants do insight and learn skills about delivering palliative care not need to have access to these materials during in newer practice models such as the Emergency the live review course. Department, the ICU and the outpatient arena. Impor- Ò tantly, we will use active learning strategies to emphasize CHPN Certification Review: best practices for transitioning patients between pallia- Registered Nurse (P08) Ò tive care settings. These strategies will aim to position Cynthia Stafford, MSN GNP-BC ACHPN , Carolinas patients and providers to achieve optimal clinical, hu- Healthcare System, Concord, NC. Barbara Schmal, Ò manistic and economic outcomes throughout the tran- MS RN CHPN , Hospice of the Valley, Phoenix, AZ. sition. Learners will leave with practical skills they can Objectives implement immediately in their practice. Provide participants with a framework to prepare Ò for Certified Hospice and Palliative Nursing Ò ACHPN Certification Review: Advanced (CHPN ) Examination. Practice Registered Nurse (P07) Provide participants with a process to assess Kerstin Lappen, MS ACNS-BC ACHPN FPCN, Minne- strengths and weaknesses of content for the Ò sota Oncology, Minneapolis Clinic, Minneapolis, MN. CHPN Examination. Ò Peggy Bishop, MSN ACNS-BC AOCN ACHPN, Sentara The purpose of this HPNA Endorsed CHPN Review Martha Jefferson Hospital, Charlottesville, VA. Course is to support nurses desiring to advance their Objectives professional development through specialty hospice Provide participants with a framework to prepare and palliative nursing certification. This one-day pro- for Advanced Certified Hospice and Palliative vider-directed, provider-paced live intensive course is Ò Nursing (ACHPN ) Examination. designed to assist with preparation for the hospice Provide participants with a process to assess and palliative nurse certification exam through didac- strengths and weaknesses of content for the tic course presentation with active learner engage- Ò ACHPN Examination. ment, case study examinations, practice exam Ò The purpose of this HPNA Endorsed ACHPN Review questions and self-check/reflection to highlight self- Course is to promote education of the APRN seeking identifying topics that require further preparation Ò augmentation of their professional development and study in advance of sitting for the CHPN 308 Schedule With Abstracts Vol. 53 No. 2 February 2017

Ò specialty certification examination. This CHPN Certi- of patients with advanced cardiac disease. Each pre- fication Review Course provides a review of the con- senter will touch on how they interact with advanced tent areas based upon the Hospice and Palliative cardiac disease providers at their own institutions, and Credentialing Center (HPCC) detailed test content will give basic to intermediate-level information about outline. The educational content may also be used how palliative care engages patients with cardiac condi- to increase the hospice and palliative nurse’s knowl- tions. This session is recommended for providers with edge of palliative nursing. Our HPNA faculty are na- any level of experience in caring for patients with car- tional subject matter experts with career experience diac disease, and does not have a prerequisite of experi- in hospice/palliative care and certified by the Hospice ence or knowledge. Presenters will assume that and Palliative Credentialing Center in the specialty of attendees may have had a broad range of previous expe- Hospice and Palliative Care. rience in caring for patients with cardiovascular dis- Attendees of this session will require the following eases, including some attendees that may have no or adjuvant materials: Core Curriculum for the Hospice and minimal experience to date. Palliative Registered Nurse, 4th edition (order online from the HPNA Shop) and the Hospice and Palliative Credentialing Center CHPN Candidate Handbook Priming the System for Primary Palliative (download and print for free at http://hpcc. Care: More, Better, and Earlier advancingexpertcare.org/competence/rn-chpn/). The Conversations with Seriously Ill participants do not need to have access to these mate- Patients (P10) rials during the live review course. Justin Sanders, MD MSC, Dana-Farber Cancer Insti- tute and Harvard Medical School, Boston, MA. Joshua Lakin, MD, Harvard Medical School, Boston, MA. Ra- 8e11:45 am chelle Bernacki, MD MS FAAHPM, Dana-Farber Can- cer Institute, Boston, MA. Catherine Arnold, MSW Getting to the Heart of the MatterdAn LICSW, Brigham & Women’s Hospital, Boston, MA. Overview of Advances in Cardiac Palliative Joanna Paladino, MD, Ariadne Labs, Brookline, MA. Care (P09) Objectives Keith Swetz, MD MA FACP FAAHPM, University of Identify the systems failures that result in absent, Alabama at Birmingham, Birmingham, AL. Jatin delayed, or inadequate serious illness Dave, MD MPH, Tufts Health Plan, Watertown, MA. communication. Shannon Dunlay, MD MS, Mayo Clinic, Rochester, Describe a systems-based approach to quality MN. Colleen McIlvennan, DNP ANP-BC, University improvement that results in more, earlier, and bet- of Colorado, Denver, CO. Sara Wordingham, MD, ter conversations about patient values and goals. Mayo Clinic Arizona, Phoenix, AZ. Patricia Davidson, Competently utilize the Serious Illness Conversa- PhD MEd RN FAAN, Johns Hopkins University, Balti- tion Guide with their own patients. more, MD. Beth Fahlberg, PhD RN AGPCNP-BC Patients with serious illness routinely receive treat- e CHPN, University of Wisconsin Madison, Madison, ments that are not in alignment with their goals and WI. Mohana Karlekar, MD, Vanderbilt University, often increase harm and suffering. The field of pallia- Brentwood, TN. tive care has shown that earlier clinical conversations Objectives about peoples’ values and priorities for living with Explain pathophysiology of heart failure and how serious illness lead to more goal-concordant care, it leads to the symptoms commonly associated improved quality of life, and greater patient and fam- with it. ily satisfaction. The Serious Illness Care Program has Recognize the role of palliative care in advanced designed a systematic approach to train and support cardiac diseases. these clinicians in conducting more, earlier, and bet- Demonstrate skills in discussing goals of care and ter conversations about goals of care with their seri- needs for transitions of care with patients who ously ill patients as part of routine clinical care. have advancing heart disease. Based on a three-day CME course developed by The options for treating advanced cardiac disease are Ariadne Labs and the Harvard Medical School Center diverse and ever-evolving, and palliative care providers for Palliative Care, this workshop will provide a basic are increasingly asked to be involved in the manage- introduction to the principles, practice, and teaching ment of such patients. In this session, multidisciplinary of the Serious Illness Care Program’s systematic experts in palliative care and cardiologydincluding approach to improving the care of patients with serious heart failure, cardiac devices, symptom management, illness through a process that integrates more, better, care transitions, and caregiver supportdwill explore and earlier conversations about goals and values into how they approach the evaluation and management routine clinical processes. Elements of this approach Vol. 53 No. 2 February 2017 Schedule With Abstracts 309

include identification of appropriate patients; training suffering. This is true for clinician and patient alike. In and prompting of clinicians; facilitation of high quality this workshop, we will make use of poetry as a healing mo- discussions using a structured conversation guide; ma- dality to enhance listening skills, and offer the possibility terials that support patients to more easily discuss these of deepening dialogue with our own hearts, minds and issues with their loved ones; and structured approaches spirits, as well as with those we care for professionally. to documentation in the medical record. Teaching Through experiential exercises, dialogue, and contem- methods include didactic presentations, large group plation, we will create a safe environment in which to interactive sessions and small group skills-based explore the relationships between science and art, words training and personalized feedback. Participants in and medicine, the personal and the universal. this workshop will increase their personal effectiveness and comfort in conducting end-of-life discussions using Beyond Resilience: Cultivating Compassion a systematic approach, and will explore basic strategies and Gratitude (P12) to teach this approach to others. Ronald Epstein, MD FAAHPM, University of Roches- ter, Rochester, NY. Fred Marshall, MD, University of Palliative Care and the Art of Poem Making: Rochester, Rochester, NY. A Pathway to Deepen Dialogue with Objectives Ourselves, Our Patients, Our Understanding the nature of burnout and resil- Colleagues (P11) ience and the role of positive and pro-social Judith Redwing Keyssar, RN BA, Jewish Family and Chil- emotions dren’s Services, San Francisco, CA. Michael Rabow, MD Characterizing their own unhealthy reactions, sur- FAAHPM, University of California San Francisco, San vival strategies and healthy responses to stress Francisco, CA. Merijane Block, BA, University of Cali- Demonstrating ways they can foster resilience, fornia San Francisco, San Francisco, CA. John Fox Cal- fulfillment and well-being ifornia Institute of Integral Studies, Palo Alto, CA. Palliative care, which promotes compassionate care Objectives amid serious illnesses, depends on practitioners’ abil- Identify two ways they might improve their ity to cultivate attentiveness, compassion, resilience communication with patients through the use of and mindfulness in their interactions with patients, poetry/writing. families and colleagues. The AAHPM prioritizes Integrate poem-making/writing into their prac- ‘‘identifying opportunities for enhanced self-care tice of self-care, self-understanding and self-accep- and resilience’’ as a key objective for its annual con- tance and demonstrate the effectiveness of this ference sessions. Yet, although it is known that peo- experience in clinical settings. ple can enhance their capacity for resilience, Create a plan of care for appropriate patients that addressing burnout and promoting resilience in includes using poetry as a healing modality. health care settings has been elusive. Resilience is ‘‘We may have lost faith in our ability to write poems, especially important in palliative care, where clini- just as we have lost faith in our ability to heal. Recov- cians confront loss, grief, conflict and difficult deci- ering the poet strengthens the healer and sets free sions on a daily basis. the unique song that is at the heart of every life.’’ New evidence suggests that cultivating positive emo- dDr. Rachel Naomi Remen, from preface to Poetic tions (e.g. gratitude) and compassionate action Medicine: The Healing Art of Poem-Making, by John Fox reduce burnout and enhance resilience. This work- In our busy professional lives as palliative care clinicians, shop will offer an experiential introduction to mindful there are few sanctioned opportunities to examine our practice with a focus on resilience, positive emotion emotional and psychological experiences and our rela- (e.g., gratitude) and compassion, based on workshops tionships with patients. Similarly, as patients, there are for health professionals which have resulted in greater few opportunities offered by our healthcare system to resilience, empathy and psychosocial orientation while allow expression of the deeper issues influencing the ca- reducing burnout (see RM Epstein, JAMA 1999, MS pacity to consider and accept a diagnosis or experience Krasner JAMA 2009, HB Beckman et al Acad Med healing. For patients, and for clinicians working with peo- 2012). Participants will practice bringing forth their ple facing serious illness and/or the end of life, the use of capacity for gratitude and compassion through secular poetry and creative self-expression can deepen the thera- contemplative practices, paired dialogues using appre- peutic potential of the work and transform the experience ciative inquiry and insight dialogue techniques, and of the healing process. The practice of ‘‘poem making’’ discussion of ways to experience greater resilience in can offer access to the body’s deep wisdom and the means work settings. We will review psychological and neuro- to express, through metaphor and image, something that cognitive underpinnings of resilience; present evi- helps us discover meaning in even our most intense dence that resilience can be cultivated; and propose 310 Schedule With Abstracts Vol. 53 No. 2 February 2017

individual, team, and institutional efforts that pro- Learn to maximize the use of resources through mote resilience. No prior experience is necessary. observing learner engagement. The session is a faculty development workshop de- Now in 3D: Managing Geriatric Delirium, signed to give learners insights and tools to build Dementia, and Dementia Related actor-based simulation at their institution and consider Behavioral Disturbances (P13) the resources required. Educational needs in palliative care are substantial, and there is often little or no oppor- AAHPM Leadership Forum: tunity for deliberate practice with feedback. Recent ef- IgnitedUtilizing DISC Behavioral Styles to forts to improve the education of Advanced Care Increase Leadership and Team Effectiveness Planning facilitators through the use of actor-based in Palliative Care and Hospice simulation will be demonstrated and shared. This will Settings (P14) include: video vignette examples, templates for case Lisa A. Bouchard, CPBA CPMA, Data Dome, Inc., development, actor scripting templates, debriefing Atlanta, GA. scripting templates, methods and forms for observing learner engagement, and examples of assessments Objectives and evaluations. The workshop is hands-on with the d Understanding the DISC Methodology Recog- goal of learners developing their own simulations that nizing your strengths and limitations as a leader target their learners’ educational needs. Simulations d Understanding Your Team How to best manage, may be designed to meet the entire spectrum of motivate, and communicate with them learners in palliative care and may easily be built to d Understanding Your Patients (and Family) Rais- include interprofessional learning objectives. ing awareness of their needs, concerns, and how to make better decisions together Palliative care and hospice settings can be filled with Oncologist in My Pocket: What the Hospice stress, change, and tension. What separates the best or- & Palliative Provider Needs to Know About ganizations from the struggling are strong leaders that Hematology/Oncology (P16) focus on building highly productive teams. This half- Kristina Newport, MD FAAHPM, Hospice & Commu- day session will focus on utilizing the DISC Behavioral nity Care, Lancaster, PA. Barton T. Bobb, MSN FNP- Styles methodology to take your leadership skills and BC ACHPN, VCU Health Massey’s Thomas Palliative team to the next level. Awareness of behavioral styles Care Service, Richmond, VA. Thomas LeBlanc, MD directly impacts trust, collaboration, and engagement. MA, Duke University School of Medicine, Durham, Participants will complete a personalized DISC profile NC. Shanthi Sivendran, MD, PENN Medicine at Lan- which will help to determine how to best leverage caster General, Lancaster, PA. their style to build the most effective team. They will Objectives also learn how to adapt their communication to the Verbalize the need for increased knowledge of specific style needs of both team members and pa- topics in Hematology/Oncology. tients, leading to stronger relationships, better deci- Define and describe the language and assessment sions, and unprecedented results. tools utilized by Hematologist/Oncologists. Describe available treatment and prognosis for 1:15e5pm advanced solid tumor malignancies including chemo- therapy, immunotherapy and targeted treatments. Hospice and palliative care (HPC) providers are How to Create Actor-Based Simulations that increasingly called upon to care for patients receiving Provide Deliberate Practice with active treatment of hematologic or oncologic malig- Feedback (P15) nancies because of growing evidence that early pallia- William Bond, MD MS, OSF Healthcare, Peoria, IL. tive care improves survival, symptoms, mood, cost, Robert Sawicki, MD HMDC FAAFP FAAHPM, OSF and patient satisfaction. HPC providers may care for Health Care, Peoria, IL. Linda Fehr, BSN RN CPHQ, these patients on hospital consultation services, in OSF Healthcare System, Peoria, IL. Amy Funk, PhD, outpatient clinics, and in home hospice or palliative Illinois Wesleyan University, Bloomington, IL. Lynne care services. The need for upstream palliative care Madori OSF Healthcare System, Peoria, IL. has resulted in the development of innovative models Objectives by private insurance companies and a demonstration Learn how to build actor-based simulation sce- project by the Center for Medicare and Medicaid Ser- narios, including actor scripting. vices. To ensure success of these models, and Write and use debriefing questions that empha- encourage upstream involvement, it is imperative that size appreciative inquiry methods. HPC providers can competently care for the patients Vol. 53 No. 2 February 2017 Schedule With Abstracts 311

in question. Current hospice & palliative training and dose naloxone significantly potentiated analgesia in hu- certification does not necessarily ensure competency mans which correlated with alterations in functional con- in all essential areas. In fact, providers may not have nectivity between CNS centers. had any direct exposure to hematology/oncology care On the other dark side is opioid induced hyperalgesia. before entering the field while at the same time, care Fourteen prospective human studies have a common of patients with hematologic or oncologic malignancies finding which limits pain relief through analgesic toler- is increasingly complex. Novel therapies emerge rapidly ance or paradoxical pain. Quantitative sensory studies with mechanisms and side effects that are different of prospectively treated patients have demonstrated from traditional chemotherapy and allow for treatment increased cold pressor pain, increased temporal sum- of patients with more limited performance status. This mation (wind-up), impaired conditioned pain modula- has resulted in attendees of the AAHPM annual tion and clinically relevant increased procedure related meeting repeatedly requesting sessions to keep up-to- pain in individuals who are opioid tolerant. Recent ev- date on topics in hematology/oncology. This workshop idence suggests that all opioids cause neuroinflamma- will ensure providers are equipped with the essentials tion through Tool Like Receptors which leads to needed to approach the care of these patients, activation of glia and activation of NMDA receptors including: terminology, treatment options, unique as- The common occurrence of opioid induced hyperalge- pects of targeted therapies, hematology/oncology sia suggests that early use of adjuvant analgesics such as emergencies, hospice coverage of cancer care, ex- (þ) naloxone and (þ) naltrexone which do not pected side effects of treatments and navigating rela- interact with opioid receptors gabapentin or tricyclic tionships with hematologists/oncologists. which limit hyperalgesia may facilitate analgesia. Future Upon completion of this workshop, hospice and palli- studies are needed to confirm this supposition. ative providers will have the necessary tools to develop an approach to the care of patients with hematologic ‘‘The Doctor Is In: Part 2’’: Challenging or oncologic malignancies at any point along their Topics at the Intersection of Pediatric cancer trajectory. Palliative Care and Psychiatry (P18) Jennifer Hwang, MD MHS, Children’s Hospital of Opioid Pharmacology: The Good, the Bad, Philadelphia, Philadelphia, PA. Vanessa Battista, MS and the Ugly (P17) RN CPNP-BC, Children’s Hospital of Philadelphia, Mellar Davis, MD FCCP FAAHPM, Geisinger Medical Philadelphia, PA. Natalie Jacobowski, MD, Massachu- Center, Danville, PA. Paul A. Sloan, MD, University setts General Hospital, Boston, MA. Pamela Mosher, of Kentucky, Lexington, KY. MD MDiv, Hospital for Sick Children, Toronto, ON. Objectives Anna Muriel, MD MPH, Dana-Farber Cancer Institute, Discuss the benefits of combining opioids, either Boston, MA. Carolyn Long, MSW, Children’s Hospital bifunctional ligands or as opioid combinations. of Philadelphia, Philadelphia, PA. Discuss the evidence for opioid induced hyperal- Objectives gesia and propose that early use of adjuvants Give two examples of strategies your team can such as gabapentinoids in minimizing opioid implement when providing palliative or hospice pronociception. care for a child with a parent with major psychiat- Commercially available opioids have side effect limita- ric illness. tions and a narrow therapeutic index. Much of the prac- Describe a developmental approach to delirium tice of double opioid prescribing is by default without assessment in young children. evidence. Opioid agonist interactions may modify recep- Create a medication and behavioral plan for a tor signaling biasing downstream signaling which favors hospice patient with complex psychiatric symp- analgesia and reduces side effects. The presence of recep- toms including mania and psychosis. tor dimers means that multi-targeted opioid ligands which Unaddressed psychiatric issues can prevent us from are linked, fused or merged can target mu homodimers, providing the best care to children and their families opioid heterodimers, or opioid receptor-non-opioid re- and not all pediatric palliative care teams and pediatric ceptor heterodimers. Peptide bi-functional ligands have hospice teams have access to experts in Child and Adoles- proven effective in animal models. Combinations of oxy- cent Psychiatry who are comfortable managing children codone with morphine, sequential use of fentanyl- at the end of life. In this session, we will address three chal- morphine, combinations of morphine-methadone in an- lenging topics: (1) providing palliative care to a child imal models and in clinical studies have demonstrated when a parent has a major psychiatric illness; (2) assess- improved pain responses at lower doses. Recent studies ment and treatment of delirium in children (including suggest that functional MRI studies can help in discov- those who are preverbal); (3) treatment of children with ering and investigating opioid combinations. A recent complex psychiatric symptoms and life limiting illnesses study using nalbuphine found that the addition of low in the outpatient and home setting. In addition, we will 312 Schedule With Abstracts Vol. 53 No. 2 February 2017

have an ‘‘Ask the Experts’’ Q&A session in which partici- providers and healthcare organizations can and must pantsareencouragedtosubmitcasesandquestionsat do to mitigate their negative impact on patients. the time of conference registration which will be used to guide the second half of the session. Topics for the second AAHPM Leadership Forum: IgnitedUsing half of the session will likely include management of psy- StrengthsFinder Leadership Strategies to chosis, anxiety, depression, aggression, mania and suicidal Increase the Performance of You and Your ideation as well as general strategies to employ in the face Team in Palliative Care and Hospice of pre-existing psychiatric illness but will be tailored to the Settings (P20) requests of participants. Christina Rowe, MSOL, The Collaborative LCC, Den- ver, CO. Unconscious Bias: Improving Palliative Objectives Care Practice, Team and Self (P19) Distinguish between the 34 Talent Areas of David Hunt, JD, Critical Measures, Minneapolis, MN. Strengths for self and other team members. Tammie Quest, MD, Emory University, Atlanta, GA. Evaluate where individuals are in their develop- Objectives ment, and devise plans to encourage growth Describe the factors that trigger providers’ uncon- and improve abilities to apply talents. scious biases and how these biases contribute to Create actionable solutions to career and team disparities in patient outcomes, communication, challenges with a strengths-based approach to safety and patient satisfaction. create consistent positive outcomes. Describe the factors that trigger providers’ uncon- Would you like to discover what makes you stand out? scious biases and how these biases contribute to This half-day session will focus on utilizing a strengths- disparities in patient outcomes, communication, based approach to create consistent and positive out- safety and patient satisfaction and discover your comes to everyday challenges in hospice and palliative own personal unconscious biases by taking the care settings. Strengths are the unique combination of Implicit Association Testdthe leading tool for talents, knowledge, and skills that every person pos- measuring unconscious bias. sesses. Participants will complete a StrengthsFinder Identify concrete strategies and best practices for assessment which will help to identify personal overcoming unconscious biasesdboth for individ- strengths to focus on to become a more effective ual providers and for large healthcare organiza- leader. They will also learn how to develop these tions. In the past, human bias was regarded as strengths in order to do what they do best every day. conscious and intentional. Today, the new science Research will be presented demonstrating strengths- of bias suggests that human biases are largely un- based methods heighten personal and team engage- conscious and unintentional. ment, clearer communication, understanding, and This program will explore the scientific basis for this new overall productivity. This session will include both understanding of human bias and the implications of un- large and small group discussions, self-reflection, conscious bias theory for the health care system both in and scenario-based activities. Participants will learn terms of workforce bias and in terms of threats to clinical strategies and tactics for applying a strengths-based objectivity. In particular, participants will be exposed to approach to individual and team challenges. the Implicit Association Test, the world’s leading assess- ment instrument for measuring unconscious bias. Man- 7:30e8:30 pm agers will understand the implications of unconscious bias research for hiring, promotions, performance evalu- Plenary Session ations and risk management. Research from the AHA’s Institute for Diversity in Health Management has consis- The Rhythm of Teamwork (101) tently shown that people of color are far less satisfied with their workforce experiences and opportunities for Strong teams communicate and engage in a rhythm of advancement in the healthcare workforce than whites. give and take. The Drum Cafe uses the power of Research documents the fact that providers’ uncon- rhythm and the universality of music to quickly engage scious biases contribute strongly to disparities in care to and energize. Experience harmony and teamwork racial and ethnic minorities, language access patients with this interactive drumming event. The Drum and other historically disadvantaged groups. Uncon- Cafe began in Johannesburg, South Africa, influenced scious biases strongly influence providers’ communica- by the experience of communal drumming and the tion and treatment of patients and thus directly impact passion to unite different groups of people in the patient satisfaction. This webinar will explore what trig- country’s post-apartheid era. Don’t miss this exciting gers providers’ unconscious biases and what individual and unforgettable start to the Annual Assembly. Vol. 53 No. 2 February 2017 Schedule With Abstracts 313

Thursday, February 23 developing a comprehensive process for eligibility/ certification/recertification by using appropriate 7e8am prognostication tools, regular clinical assessment, and clinical judgement documentation can support Concurrent Sessions appropriate care for eligible hospice patients even if they live beyond a predetermined prognosis. Devel- oping efficient strategy for discharging patients no How to Address Clinical and Regulatory longer eligible, or readmitting patients who again Issues for Eligible Hospice Patients Living become eligible, is also an important process, partic- Past Their Expected Prognosis (TH300) ularly for patients living beyond their prognosis. Todd Cote, MD HMDC FAAFP FAAHPM, Hospice of Hopefully, determination of hospice eligibility stays the Bluegrass, Lexington, KY. Salli Whisman, MD, within the hands of physicians and hospice medical Hospice of the Bluegrass, Lexington, KY. Robert Fried- directors working with other hospice interdisciplinary man, MD HMDC FAAFP FAAHPM, Hospice Austin, team experts. The current healthcare regulatory envi- Austin, TX. Eugenia Smither, BS RN CHP CHE, Hos- ronment challenges this basic concept. It is critical for pice of the Bluegrass, Lexington, KY. Jim Gaffney, MD hospice medical directors to take a lead role in mak- MBA, Hosparus, Louisville, KY. Lori Earnshaw, MD, ing sure all eligible patients receive timely hospice Hosparus, Louisville, KY. care, even if their time exceeds what was expected. Objectives Describe the similarities and differences between prognostication, hospice eligibility and eligibility Evidence-Based Interventions for Treating for Claims Data on Hospice Patients. Dyspnea in Advanced Disease and at the Utilize appropriate hospice team education, tools End of Life: A Report from the HPNA and process to ensure high quality appropriate Dyspnea Task Force (TH301) care for eligible hospice patients living past their Margaret Campbell, PhD RN FPCN, Wayne State Uni- expected prognosis. versity, Detroit, MI. Lynn F. Reinke, PhD ARNP ANP- Understand continued regulatory scrutiny of hos- BC, VA Medical Center, Edmonds, WA. DorAnne Do- pice care for long length of stay patients and the nesky, PhD ANP-BC ACHPN, University of California, varied approaches Medicare Administrative Con- Benicia, CA. Deborah Thorpe, PhD ANP-BC ACHPN, tractors (MACs) and other government audit con- Rocky Mountain Hospice, Salt Lake City, UT. Beth tractors have toward the issue. Fahlberg, PhD RN AGPCNP-BC CHPN, University of e One of the most difficult challenges for a hospice, Wisconsin Madison, Madison, WI. Alison Walsh, RN, and the hospice medical director, is how to approach Pennsylvania State University, State College, PA. thehospicepatientthatlivespasttheirexpected Objectives prognosis. As we know, nationally 12%-15% of pa- Describe the process used to search and critique tients admitted to hospice service live past their ‘‘6 the evidence about dyspnea treatment. months of life or less’’ prognosis. The Center for Describe levels of evidence. Medicare and Medicaid Services (CMS) and govern- Describe dyspnea interventions ranked by level of ment audit contractors continue to scrutinize hos- evidence. pice ‘‘long length of stay’’ patients. This coincides Dyspnea is one of the worst symptoms experienced by with continued difficulty in predicting a prognosis most patients with advanced illness and at the end of of ‘‘6 months or less’’ using current prognostication life. The evidence-base for dyspnea interventions lags science. Traditionally, eligibility criteria have been behind what is known about treating pain. Yet, nurses used by Medicare Administrative Contractors and physicians face the challenge of treating this (MAC) to analyze hospice claims for payment. The symptom every day. A Task Force (TF) of the Hospice developmentofthesetypesofcriteria,oftenlacking and Palliative Nurses Association (HPNA) undertook scientific scrutiny, has not been well understood a charge to search and critique the dyspnea interven- and continues to play a prominent role in hospice tion evidence base to create a summary report. In audits. consultation with the ONS ‘‘Putting Evidence into It is important for the hospice medical director to un- Practice’’ project leaders this HPNA TF agreed to cate- derstand how utilizing developing prognostication gorize the evidence into the following levels: 1) recom- science, along with proper, ongoing assessment of mended for practice, 2) likely to be effective, 3) hospice patients, can assist the hospice team to care effectiveness not established, 4) benefit balanced for appropriate, eligible hospice patients. Proactively with harm, and 5) not recommended for practice. 314 Schedule With Abstracts Vol. 53 No. 2 February 2017

TF members undertook a systematic process with sup- advancing age, psychiatric comorbidity, male sex, port from an academic librarian for dyspnea interven- AIDS diagnosis, a family history of suicide, and uncon- tion studies from 1990 to present. Studies about adult trolled symptoms. Cancer patients have nearly twice samples with dyspnea as the primary or secondary the incidence of suicide relative to the general popula- dependent measure were identified. Manuscripts tion. Depression, hopelessness, loss of control and fa- were excluded if they were case reports, opinion tigue increase a patient’s vulnerability to suicidal pieces, letters to the editor, expert consensus, or small thoughts. Assessment of suicide risk and appropriate pilot studies. Search terms included: dyspnea, breath- intervention are critical. Early comprehensive psychiat- less, advanced disease, COPD, heart failure, lung can- ric involvement with high-risk individuals can avert sui- cer, dementia, ALS, end of life, refractory, opioids, cide. Despite all measures a patient may still take his or benzodiazepines, bronchodilators, anticholinergics, her own life. The impact of completed suicide on oxygen, medical air, bipap, cpap, fans, CAM, and posi- healthcare professionals often leads to feelings of tioning. The initial search identified 472 manuscripts. anger, sadness, anxiety, guilt, embarrassment, helpless- After a title search, using project inclusion criteria, we ness, questioning, even symptoms of post-traumatic narrowed the evidence pool to 122 manuscripts. A stress disorder. These responses have profound effects face-to-face meeting at the 2016 annual assembly af- on clinicians’ behavior including loss of self-confi- forded reconciliation of disagreements to an evidence dence in professional judgment, preventive overutiliza- pool of 102 papers. Subsequently, the task force tion of hospitals, hypervigilance with respect to suicide divided the papers for data extraction and evidence and patient care, and preoccupation with medico-legal level categorization; each paper was reviewed by two concerns. This multidisciplinary session consisting of task force members. palliative care specialists, psychiatrists, social work Conference calls followed and were used to reach and chaplaincy will enable attendees to: 1.) Recognize agreement about levels of evidence and final report risk factors for suicide in the hospice population; 2.) generation. The processes and final report will be pre- Learn to assess patients expressing suicidal ideation sented in this concurrent session. and when to make the call to the psychiatrist 3). Un- derstand the differential diagnoses associated with ex- ‘‘Mr. Smith Killed Himself Last Night’’: The pressing feelings of wanting to die, 4.) Recognize the Scope of Suicidality in Hospice Care impact of suicide on staff. 5). Learn methods of (TH302) dealing with adverse reactions to loss. 6.) Recognize Martina Meier, MD, Providence TrinityCare Hospice, the impact of suicide on the families of patients with Los Angeles, CA. Eric Prommer, MD HMDC advanced illness 7.) Learn about implementation of FAAHPM, Greater Los Angeles Healthcare, Los An- suicide prevention programs in hospice. geles, CA. Scott Irwin, MD PhD, Cedars-Sinai Health System, Los Angeles, CA. Shannon Deslauriers, Ventricular Assist Devices (VADs) in MSW, Providence TrinityCare Hospice, Los Angeles, Children: Present and Future Considerations CA. Richard Ortolano, MA, Theology MA Spiritual for Pediatric Heart Failure and Palliative Psychology, Providence TrinityCare Hospice, Los An- Care Team Collaboration (TH303) geles, CA. Shefali Parikh, MD, Children’s Hospital of Philadel- Objectives phia, Philadelphia, PA. Beth Kaufman, MD, Lucile Identify risk factors for suicide in patients with Packard Children’s Hospital, Palo Alto, CA. Gina San- advanced illness. tucci, MSN FNP-BC APRN, Children’s Hospital of Phil- Learn to assess and respond to the patient exhib- adelphia, Philadelphia, PA. iting suicidal ideation or other thoughts of Objectives wanting to die. Identify which groups of children with severe Recognize the impact of suicide on the hospice and/or intractable heart failure may be a candi- team and families. date for a ventricular assist device (VAD). One of the most challenging aspects of hospice care is Review current guidelines for patients receiving helping the patient with advanced illness physically, VADs, specifically pediatric consideration psychologically and spiritually through the dying including the need for an interdisciplinary and process. Patients with advanced cancer, and other palliative approach. life-threatening medical illnesses, experience an enor- Examine how to best prepare the child, family mous burden of both physical and psychological symp- and caregiver when a VAD is being initiated toms. When the limits of distress are reached, suicide and/or deactivated. may be contemplated as an option for those with Ventricular assist devices were initially used to support advanced illness. Risk factors for suicide include adults with heart failure as a ‘bridge to transplant’ and Vol. 53 No. 2 February 2017 Schedule With Abstracts 315

later as a ‘destination therapy’ (DT) in patients ineli- versus opting for conservative management very chal- gible for heart transplant. Relatively recently, VADs lenging. Several tradeoffs that impact quality of life have become an option for children with end-stage need to be considered when making these important de- heart failure either as a bridge to transplant or recov- cisions. The timing and content of conversations ery. The use of VADs as destination therapy for chil- regarding advance care planning in this population, dren is evolving, as new long term support devices particularly when the risks begin to outweigh the bene- appropriately sized for children are more readily avail- fits, also poses significant challenges. Therefore, a able. Patients who may benefit from these devices comprehensive, interdisciplinary approach that incor- include those with Duchenne muscular dystrophy, porates PM into the facilitated discussion could benefit children with ongoing malignancy and chemo- patients, caregivers, and medical teams. therapy-related toxicity or with congenital heart dis- This interactive session will utilize an audience ease and multiple comorbidities. response system to review the evidence regarding sur- VAD support is often effective to relieve symptoms of vival rates, symptom burden, and quality of life in heart failure and therefore significantly improve qual- elderly patients with LSKD who choose conservative ity of life, however chronic anticoagulation and depen- management versus dialysis. We will discuss the chal- dence on mechanical support has risk for significant lenges of advance care planning in this population, morbidities and caregiver burden. There are physical, including timing and perceptions of hospice enroll- social, and emotional strains on the child and family ment. Finally, we will present a series of clinical sce- distinct from adults that are important to consider narios that incorporates the evidence into a shared during decision-making related to VAD as DT in a decision-making model to assist PM clinicians in con- child. Examples are re-integration into school and structing a value-based discussion. age-appropriate shared decision-making. In this ses- sion, we will discuss indications for VADs in children, Building Payer-Provider Partnerships for types of devices, outcomes, current guidelines and Innovative Palliative Care Models (TH305) future considerations including advance care plan- Jatin Dave, MD MPH, Tufts Health Plan, Watertown, ning and ethical implications. MA. Parag Bharadwaj, MD FAAHPM, Sentara Health- care, Virginia Beach, VA. Tom Gualtieri-Reed, MBA The Dreaded Dialysis Discussion: What the BA, Spragens & Associates LLC Chapel Hill, NC. Evidence Shows and How to Effectively Dana Lustbader, MD, ProHEALTH, Great Neck, NY. Facilitate the Conversation (TH304) Bruce Smith, MD, Regence BlueShield, Seattle, WA. Aziz Ansari, DO, Loyola University Medical Center, Objectives Maywood, IL. Stacie Levine, MD FAAHPM, University Describe the value of Palliative Care from payer of Chicago, Chicago, IL. Laura Fosler, MS FNP-BC and provider perspective to achieve quadruple ACHPN, Rush University Medical Center, Chicago, IL. aim. Objectives Describe actions payers are taking to integrate Identify the impact of initiating dialysis in pa- palliative care into payment models, care manage- tients with late stage kidney disease (LKSD) with ment programs, and benefits. multiple co-morbidities. Identify the critical steps necessary to build effec- Review the effects on functional status after start- tive payer-provider partnerships to support those ing dialysis in the elderly. with serious illness. Discuss challenges regarding advance care plan- Recent changes in the health care environment with ning in patients with LSKD. shifting and shared risk have created unique opportu- There is growing interest in the role of palliative medi- nities for payers and palliative care providers to part- cine (PM) support in the renal population. Many pa- ner in the care of the most medically complex tients with late stage kidney disease (LSKD) experience individuals. There is an increasing focus on the symptom burdens and mortality rates similar to those quadruple aim: better care, better health, lower costs with advanced malignancies. Although patients with and improving the work life of those who deliver LSKD often choose dialysis, it may not offer a survival care. Considering the added value of palliative care advantage in the elderly, especially those with multiple and challenges in adequate volume-based reimburse- comorbidities, functional impairment, and chronic ment for palliative care, such payer-provider partner- malnutrition. Complications from falls, cognitive impair- ships are essential for creating sustainable models of ment, vascular access failure, and infections lead to palliative care across settings. further concern for worsening morbidity and psychoso- Through success stories, data, case examples, and group cial decline after initiating dialysis. In addition, prog- discussion, this session will focus on how palliative care nostic uncertainty makes the choice of starting dialysis can support the quadruple aim. By comparing provider 316 Schedule With Abstracts Vol. 53 No. 2 February 2017

and payer needs, the presenters will share strategies to After a brief review of the literature around transition align priorities to create innovative partnerships. The management and burnout, participants will explore po- presenters will discuss how such partnerships can help tential transitions that are on their horizon in their per- support palliative care across the continuum: home, sonal and professional lives, and to consider both the outpatient, inpatient, and post-acute care. Presenters barriers and opportunities that lay ahead. Participants will provide details of different types of models across will be asked to commit to two things they can do the care continuum, including chronic care of the when they return home to proactively work on transi- medically complex, palliative care and hospice models. tions that are in their horizons. Finally, the presenters will identify barriers in building effective payer-provider partnerships and practical stra- Measuring What Matters Forum: Making tegies to overcome those barriers. The materials pre- Your Quality Efforts Matter When You Don’t sented will be brainstormed in small and large group Make the Rules! (TH308) discussions facilitated by the session’s faculty. Partici- Joseph Rotella, MD MBA HMDC FAAHPM, American pants will have time to develop and work on plans for Academy of Hospice and Palliative Medicine, Chicago, their own organizations. IL. Lisa C. Lindley, PhD RN, University of Tennessee, Knoxville, TN. Arif Kamal, MD MHS, Duke Cancer Proactively Managing Our Own Transitions Institute, Durham, NC. (TH306) Objectives Timothy Quill, MD FACP FAAHPM, University of Ro- Describe the work to date of the Measuring What chester Medical Center, Rochester, NY. Charles Well- Matters initiative and the key findings from a man, MD FAAHPM, Hospice of the Western Reserve, recent AAHPM and HPNA member survey on Cleveland, OH. Martha Twaddle, MD HMDC FACP quality improvement needs. FAAHPM, JourneyCare, Glenview, IL. Describe the key quality reporting requirements Objectives under MACRA. Discuss strategies for successful career transition Outline steps HPM clinicians can take to make anticipation and management, and to understand their quality efforts matter under CMS quality re- some of the warning signs when transition plan- porting programs. ning should be considered. A panel of HPNA and AAHPM leaders engaged in Illustrate personal challenges and opportunities pro- Measuring What Matters will provide an update on vided by transitions in our own professional and per- the project, including results of a recent member sur- sonal lives, and to commit to begin to address them. vey on quality improvement needs. The Medicare Ac- Large group reflection, comments and questions. cess and CHIP Reauthorization Act of 2015 While palliative care clinicians pride themselves in (MACRA) increases the linkage of quality reporting their ability to help patients and families work though to payment. Most palliative medicine clinicians prac- very daunting transitions, we are often less proficient ticing in community settings will be subject to the at skillfully anticipating and negotiating our own tran- Merit-Based Incentive Payment System (MIPS). Most sitions, especially in the professional realm. Much of of the measures included in MIPS have little or no this difficulty is characterologicaldwe are more relevance to palliative care. So how can palliative med- comfortable and more skilled at helping others to icine clinicians meet the pay-for-reporting require- look inward to identify what is needed than we are ments and still engage in quality improvement that at doing the same for ourselves (much less asking really matters for their patients? Speakers will provide for help in the process). The net result of this avoid- clinicians with tips for making the required quality re- ance may be an increasing likelihood of becoming porting work for them in spite of systems that weren’t burned out before making timely transitions that designed with palliative care in mind. might be needed. Ironically, many clinicians came to palliative care after becoming burned out working in their original field, and risk continuing this pattern Paper Session if they do not better understand and then proactively address the process. In this session, participants will be introduced to a strat- Prioritizing Outcomes for Advance Care egy for proactively identifying the need to make small Planning Research: Consensus from a or large transitions, hopefully before becoming burned Multidisciplinary, International Delphi out. Warning signs for needing to make changes on the Panel (TH307A) job will be identified, as well as common personal as Rebecca Sudore, MD, San Francisco VA Medical Cen- well as institutional barriers to initiating these changes. ter & University of California San Francisco, San Vol. 53 No. 2 February 2017 Schedule With Abstracts 317

Francisco, CA. John You, MD MSc, McMaster Univer- Conclusion. A large, international Delphi panel sity, Hamilton, ON. Ida Korfage, PhD, Erasmus Uni- came to consensus about an Organizing Frame- versity Medical Center, Rotterdam, Netherlands. work and important outcomes to define successful Judith Rietjens, PhD, Erasmus University Medical Cen- ACP. ter, Rotterdam, Netherlands. Gem Le, PhD MHS, Uni- Implications for research, policy or practice. This versity of California San Francisco, San Francisco, CA. work will allow researchers, healthcare organizations, Daren Heyland, MD MSc FRCPC, Queen’s University, and policy makers to standardize outcomes that can Kingston, Ontario, Canada. be compared across sites. More research is needed Objectives to standardize the care consistent with goals measure. Describe an Organizing Framework developed by a large, multi-disciplinary Delphi panel regarding patient-centered ACP outcomes. A Patient-Facing Advance Care Planning Present patient-centered ACP outcomes ranked (ACP) Website Called PREPARE Increases in order of importance by a large, multi-disci- ACP Documentation and Engagement in a plinary Delphi panel. Randomized Trial of Diverse Older Primary Original Research Background. Without a shared Care Patients at a VA Medical Center understanding of standardized quality metrics that (TH307B) define successful advance care planning (ACP), it is Rebecca Sudore, MD, San Francisco VA Medical Cen- difficult to compare interventions across systems and ter & University of California San Francisco, San Fran- populations. cisco, CA. John Boscardin, PhD, University of Research Objectives. To use a large, multi-disci- California San Francisco, San Francisco, CA. Deborah plinary, Delphi panel of ACP experts to create an Barnes, PhD MPH, University of California San Fran- Organizing Framework, and identify and rank pa- cisco, San Francisco, CA. tient-centered ACP outcomes. Objectives Describe the results of a randomized control trial Methods. We first conducted literature reviews and comparing the ACP PREPARE website plus an solicited input from 5 international ACP conferences easy-to-read advance directive to an easy-to-read to collate ACP outcomes into an Organizing Frame- advance directive alone. work. Next, we conducted 3 Delphi panel rounds Discuss clinical implications of our trial findings. with a 52-member panel of researchers, clinicians, Original Research Background. We created an legal experts, and policy makers. Panelists were asked interactive, patient-centered, video-based ACP website to prioritize patient-centered outcomes, comment on called PREPARE (www.prepareforyourcare.org) and the Organizing Framework, and rank outcomes on a an easy-to-use advance directive (http://www. 7-point ‘‘not-at-all’’ to ‘‘extremely important’’ scale. iha4health.org/our-services/advance-directive/). We used content analysis of panelists’ comments to Research Objectives. To determine whether PRE- iteratively update the Framework and outcomes and PARE, versus an advance directive (AD) alone, in- present data back for Delphi panel review. We also creases ACP among older primary care patients. calculated the mean rankings ( SD). Methods. Participants were from the San Francisco VA, Results. Panelists were from USA, Canada, were $60 years old, had $two chronic/serious condi- Netherlands, and Australia; 63% were women, and tions, and had seen their primary provider $twice/year. 71% were researchers. Outcome domains identified Participants were randomized to review the AD (active for the Organizing Framework included: moderators control) or the directive plus PREPARE (intervention). (i.e., demographics), process/mediators (i.e., atti- There were no clinician/system-level interventions. The tudes), actions (i.e., discussions/documentation primary outcome was new ACP documentation of ADs/ tasks), quality of care (i.e., satisfaction with care/ discussions at 6 months. Secondary outcomes included communication), and healthcare (i.e., utilization). Af- ACP engagement at 1 week, 3 months, and 6 months us- ter 3 rounds, 138 ACP outcomes were identified. The ing validated surveys that assessed behavior change Pro- top 5 outcomes included (1)care consistent with goals, cess measures (i.e., 5-point knowledge, self-efficacy, mean 6.70 (SD 0.31); (2)surrogate designation, 6.68 readiness scales) and Action measures (e.g., surrogate (0.44); (3)surrogate documentation, 6.48 (0.39); (4) designation, 0-25 scale). We used intention-to-treat discussions with surrogates, 6.44 (0.33); and (5)identi- mixed-effects logistic and linear regression, controlling fying values and goals 6.40 (0.62). Documentation of for time, literacy, race/ethnicity, baseline ACP and clus- an advance directive was ranked 14th, 5.98 (0.59). tered by physician. The panel was unsure how to best measure care consis- Results. Mean age of 415 participants was 71 years ( tent with goals. 8), 9% were women, 17% had limited literacy, and 318 Schedule With Abstracts Vol. 53 No. 2 February 2017

43% were non-white. No participant characteristics US sites), we systematically eliminated questions based differed between arms (p>0.05). Follow-up at 6- on face validity, item non-response, redundancy, ceiling months was 90%. New documentation was higher effects, and factor analysis. For construct validity (English- with PREPARE plus an AD versus an AD alone and Spanish-speaking participants from 3 ongoing US (adjusted 35% vs. 25%, OR 1.61 (CI: 1.03-2.51)). PRE- randomized ACP trials), we assessed internal consistency PARE also resulted in higher mean 5-point Process using Cronbach’s alpha, cross-sectional correlations, and scores at each follow-up and overall from baseline the ability of the progressively shorter surveys to detect (baseline 3.2 & 3.3: 1week 3.7 vs 3.5, 3 months 3.8 vs change one week after exposure to an ACP intervention 3.5, 6 months 3.8 vs 3.6, p<.001) and higher 0-25 Ac- using Pearson’s correlation coefficients. tion scores (baseline 11.7 & 12.5: 1week 14.7 vs 13.7, 3 Results. 501 participants were included in item reduc- months 15.3 vs 14.4, 6 months 15.0 vs 14.8, p<.001). tion (age 69 years (10), 41% non-white). Due to high Conclusion. The purely patient-facing, ACP PREPARE correlations (mean 95% correlation, 6) between readi- website plus an easy-to-read advance directive compared ness and action items, all action-items were removed. to a directive alone increased ACP documentation and Due to high correlations and ceiling effects, 2 additional engagement among diverse older adults. process-items were removed. Successive factor analysis Implications for research, policy, or practice. then created 55, 34, 15, 9, and 4-item versions. 664 partic- Although integrated patient/clinician/system-level ipants were included in the construct validity analysis (age ACP interventions are needed, this study suggests that 65 years (8), 72% non-white, 34% Spanish-speaking). PREPARE is an effective strategy for increasing ACP. Cronbach’s alpha was high for all versions (4-item, 0.84 to 55-item, 0.97). Compared to the original survey, Measuring Advance Care Planning: cross-sectional Pearson’s correlations were high (4-item, Optimizing the Advance Care Planning 0.85 to 55-item, 0.97) as were correlations detecting Engagement Survey (TH307C) change (4-item, 0.68 to 55-item, 0.93). Correlations re- mained high for English and Spanish-speakers. Rebecca Sudore, MD, San Francisco VA Medical Cen- Conclusion. Shorter versions of the ACP Engage- ter & University of California San Francisco, San Fran- ment Survey are valid, internally consistent, and able cisco, CA. Daren Heyland, MD MSc FRCPC, Queen’s University, Kingston, Ontario, Canada. Deborah to detect change across a broad range of ACP behav- iors for English and Spanish speakers. Barnes, PhD MPH, University of California San Fran- Implications for research, policy or practice. cisco, San Francisco, CA. Michelle Howard, PhD, Shorter ACP Surveys can efficiently and effectively McMaster University, Hamilton, Ontario, Canada. measure broad ACP behaviors in research and clinical Konrad Fassbender, PhD, Covenant Health Palliative settings. Institute, Edmonton, Alberta, Canada. Carole Robin- son, PhD RN, University of British Columbia, Kelow- na, British Columbia, Canada. John Boscardin, PhD, Using A Video-Based Advance Care University of California San Francisco, San Francisco, Planning (ACP) Website to Facilitate Group CA. John You, MD, McMaster University, Hamilton, Visits for Diverse Older Adults in Primary Ontario, Canada. Care Is Feasible And Improves ACP Objectives Engagement (TH307D) Carly Zapata, MPH MD, University of California San To describe a systematic process to reduce survey Francisco, San Francisco, CA. Emily Wistar, MD, Uni- items on the validated Advance Care Planning versity of California San Francisco, San Francisco, Engagement Survey. CA. Claire Horton, MD MPH, University of California To describe a systematic process to validate pro- San Francisco, San Francisco, CA. Hillary Lum, MD gressively shorter versions of the Advance Care PhD, University of Colorado and Eastern Colorado Planning Engagement Survey. GRECC, Aurora, CO. Rebecca Sudore, MD, San Fran- Context. A validated 82-item Advance Care Planning cisco VA Medical Center & University of California San (ACP) Engagement Survey measures a broad range of Francisco, San Francisco, CA. behaviors (i.e., discussions and documentation). How- ever, concise surveys are needed. Objectives Research Objectives. To validate progressively short- To assess the feasibility of a video-based website to er versions of the ACP Engagement Survey. facilitate group visits for advance care planning. Methods. The original Survey includes 57 Process Mea- To engage a group of diverse older adults in a safety sures (i.e., knowledge, contemplation, self-efficacy, and net primary care setting in advance care planning. readiness) and 25 Action Measures across 4 domains (sur- Original Research Background. Primary care pro- rogates, quality of life, flexibility, and asking questions). viders in safety-net settings often do not have time to For item reduction (participants from 4 Canadian and 3 discuss advance care planning (ACP). However, ACP Vol. 53 No. 2 February 2017 Schedule With Abstracts 319

group visits (GV) may be an efficient way to provide narrativesdstoriesdto the work we do in hospice and ACP education. palliative care. Taking to heart novelist E.M. Forster’s Research Objectives. To assess the feasibility of a admonition to ‘‘only connect,’’ Brown will discuss her video-based website to facilitate ACP GVs and to own writing and how it has made her a better caregiver. engage diverse, older adults in ACP. She will then explore the value and importance of pa- Methods. We conducted a feasibility pilot among tients’ stories, showing that illness tells a story, as does patients from two primary care clinics in a Northern care. Hospice does not aim to cure, but care is central California safety net setting who were $ 55 years of to the mission. How does that story of medical care age with $ 2 chronic/serious conditions. Participants withoutcuredevelop?Tobegin,wemustfirstconnect attended two 90-minute GVs and viewed the with the patient. 5-step videos of the PREPARE program (www. prepareforyourcare.org) concerning surrogates, values, and discussing wishes. Two clinician facilitators 10:45e11:45 am were available to answer questions and encourage participation. We assessed pre-to-post ACP knowledge Concurrent Sessions (percent correct) and whether participants designated a surrogate or completed an advance directive using Fisher’s exact tests. We assessed ease-of-use of the GV Building a Palliative Care Program in and PREPARE materials on a 10-point scale. Primary Care for the Underserved: Results. We conducted two GVs with 22 participants, Challenges and Preliminary Outcomes 9 and 13 respectively. Mean age was 64 years ( 7), (TH310) 55% were women, 73% non-white, and 55% had Earl L. Smith, MD PhD FAAPMR, Columbia University limited literacy. Preliminary findings demonstrated Medical Center, New York, NY. Margaret R. Nolan, improved knowledge about surrogate designation DNP GNP-BC ACHPN, New York Presbyterian Hospi- (46% correct pre to 85% post, p-value 0.01) and dis- tal, Bronx, NY. Cristina Ramirez-Urquiola, LCSW, cussing decisions with others (59% vs 90%, p-value New York Presbyterian Hospital, Bergenfield, NJ. Ma- 0.01). Surrogate designation increased (48% vs. ria Becerra, BSN RN, New York Presbyterian Hospital, 85%, p ¼ 0.01) and a trend toward advance directive New York, NY. Felicia Blaise, MPH MA, New York Pres- completion (9% vs. 24%, P ¼0.21). Participants rated byterian Hospital, New York, NY. Craig D. Blinderman, the GV and PREPARE materials a mean of 8 ( 3.1) MD MA, Columbia University and New York Presbyte- on a 10-point ease-of-use scale. rian Hospital, New York, NY. Conclusion. Using the PREPARE website to facilitate Objectives ACP GVs for older adults in safety-net, primary care Describe the outpatient palliative care service for settings is feasible and shows potential for increasing an underserved Medicaid urban population ACP engagement. PREPARE videos may be able to within the Delivery System Incentive Reform Pay- direct group learning in resource-poor environments ment (DSRIP) Program. or be used with other clinician-facilitated programs. Determine education interventions across a Pa- tient Centered Medical Home of 90,000 lives 8:15e10 AM across all disciplines. Practice multilingual communications strategies Plenary Session and culturally sensitive interchange. Because the need of outpatient palliative care in pre- dominantly underserved populations is so great, the Only Connect: The Essential Commingling of federal government and the state of NY developed Care and Story in Hospice and Palliative the DSRIP program to help medical homes address Care (102) this in Medicaid patients. A bilingual medical team Theresa Brown, PhD BSN RN, Hospice Nurse, Writer, was embedded in the outpatient primary care clinics and Author, Pittsburgh, PA. Patient Centered Medical Home to address the lan- Objectives guage, health literacy, and cultural barriers in this pre- Importance of listening to caring for the whole dominantly Spanish speaking population of 90,000 patient. lives. The medical team developed training programs Value of clinicians better understanding our own for the primary providers (MDs, SWs, RNs, medical work by telling our stories. residents) on how and when to perform culturally sen- In this lecture, hospice nurse and best-selling sitive discussions on goals of care and advance direc- author Theresa Brown will show the importance of tives, in addition to criteria for hospice referrals. 320 Schedule With Abstracts Vol. 53 No. 2 February 2017

Evaluation tools were developed by translating the presentation needs to be rapidly requested and per- ESAS, health care proxy and MOLST forms to more formed, but this often comes at the cost of unsavory con- culturally appropriate wording in Spanish. Criteria sequences to the patient, including threatened safety, on hospital readmissions and ER visits were put in possibly undesired health care, and comfort. We will place to identify appropriate patients for a more discuss BMC’s experience with CAGs who are charged advanced palliative care consultation, which includes to make end-of-life decisions, and reflect on the Massa- complex symptom management, prognostication chusetts state law which undergirds and informs the pro- assistance and advanced post-acute care coordination. cess. To this end, we will utilize a case study, presented Through didactics, discussion, and use of case exam- and discussed by representatives from palliative care, ples, the team created a process for forming positive law, and ethics. We will also make a concerted effort to re- alliances with primary care providers to assist the view this process in other states, juxtaposing it with our Medicaid population’s palliative care needs. Initial own, in the hope of informing others of the ability to outcomes and quality measures include number of negotiate this process within their institutions. We will ICU admissions, ICU deaths, patient and family satis- then make an effort to describe methods to try to faction, provider satisfaction and primary team gener- improve true advance care planning for this disadvan- alist palliative care skill set. taged population.

‘‘They Can’t Do That?’’ The Role of Where Payers and Providers Overlap: Court-Appointed Guardians in End-of-Life Navigating the Edge (TH312) Decision-Making (TH311) Allison Silvers, MBA, Center to Advance Palliative Diane Dietzen, MD FACP FAAHPM, Baystate Medical Care, New York, NY. Torrie Fields, MPH BA BS, Center, Springfield, MA. Christine Bryson, DO, Cambia Health Solutions, San Francisco, CA. Anna Baystate Medical Center, Springfield, MA. Peter Gosline, NA, Blue Cross Blue Shield of Massachusetts, DePergola, PhD MTS, Baystate Health, Springfield, Boston, MA. Diane Meier, MD FACP FAAHPM, Icahn MA. Barbara Stoll, JD MEd, Baystate Health, Spring- School of Medicine at Mount Sinai, New York, NY. field, MA. Objectives Objectives Define the best opportunities for palliative care Identify the population of patients you care for, providers to assume population management re- who have court-appointed guardians as their deci- sponsibilities for seriously ill patients. sion-makers, and their special-needs in advanced Evaluate two different approaches that payers are care planning. taking to ensure quality and cost-effectiveness for Recognize limitations placed on court-appointed their members. guardians for end-of-life decision-making in Describe effective mechanisms to risk stratify pa- some states. tient populations and coordinate care across pro- Discuss methods to apply this information to pa- vider organizations to meet required outcomes, tients in your practice. and consider the roles that eitherdor bothdthe In the state of Massachusetts, court-appointed guardians payer and the provider can take in these areas. (CAGs) represent patients who are incapacitated and do As health care rapidly shifts to value-based payments, a not otherwise have healthcare proxies or medical deci- strong opportunity is emerging for palliative care pro- sion-makers. Baystate Medical Center (BMC) frequently viders to capitalize on palliative care’s role in cares for such patients, who are either represented by providing quality care in a cost-effective manner. Palli- clearly appointed guardians or find themselves in urgent ative care provider organizations are striving to move need of them. These patients are frequently very sick, from fee-for-service payment systems into alternative and the goal of providers in collaborating with guardians payment models. However, moving from a patient is to make appropriate decisions regarding goals of care management approach to a population management and end-of-life plans. However, CAGs often feel uncom- approach requires providers to embrace several new fortable and ill-equipped to make these decisions, skill sets and functions: using and developing risk despite the fact that it is an elemental part of caring for stratification tools, working and sharing information patients with complex health issues. Moreover, in many across multiple provider organization, and focusing states, courts specify that guardians require special on care management of the population. How does a permission to make end-of-life decisions. These sce- palliative care organization navigate this new territory? narios present concerns which become especially acute What is the best approach to working with payers? To when the timing of critical health care or end-of-life de- begin, it is important for providers to understand the cisions do not correspond with the court’s granted au- areas where payers are generally willing to delegate re- thority to do so. Subsequently, a court hearing or sponsibility, the areas where payers take different Vol. 53 No. 2 February 2017 Schedule With Abstracts 321

approaches, and the areas where payers prefer to (encompassing preoperative, intraoperative, postopera- maintain responsibilitydand why. tive, and nonoperative management decisions), as well In this session, attendees will be introduced to this as identifying and meeting unmet palliative care needs timely topic and will hear from two representatives in the realms of prognostic determination, delivery of from large payer entities with very different ap- bad news, symptom management, and advance care proaches to managing patient populationsdone that planning. Unfortunately, common models for palliative encourages providers to manage their patient popula- care in surgical patients are limited by poor integration tions proactively and one that employs a more ‘‘hands- into the surgical workflow; the potential for undertreat- on’’ approach in working with their network providers ment (e.g., denial of surgical treatment on the basis of to ensure the delivery of high-quality, cost-effective risk, failure to rescue) and overtreatment (e.g., non- care for their members with serious illness. Specific goal-concordant attempts at rescue); the perpetuation opportunities to advance palliative care within alterna- of palliative care as a reaction to a crisis at the end of tive payment models will be discussed, along with de- life; and failure to provide earlier and better goal-setting scriptions of the challenges and successes from the and symptom management. field. Examples will be given to describe how the lines In this session, we discuss two emerging models for trig- between the payer and provider are blurring, and how gering palliative care earlier in the trajectory of care for the responsibility varies by provider. patients with surgical problems: palliative care consulta- The challenges in coordinating care across providers tion in response to system-wide frailty screening for will be highlighted, along with the strategies for build- elective surgery patients, and an interdisciplinary ing their own strong case management capabilities. referral model for palliative care assessment in patients The moderator will facilitate an interactive Q & A con- being considered for feeding tube placement in the versation with the audience, herself, and the panelists. acute hospital setting. Both models incorporate a trigger for palliative care into the preoperative work- Emerging Triggers for Palliative Care flow. Patients for whom surgical intervention is deemed Consultation in Surgery: Interdisciplinary not to be concordant with goals can avoid a nonbene- Strategies to Identify and Meet Palliative ficial intervention, and their underlying palliative care Care Needs in the Elective and Inpatient needs can be addressed earlier. Patients who elect sur- Settings (TH313) gical intervention can do so with confidence that their postoperative experience will be aligned with their pre- Ana Berlin, MD MPH FACS, Rutgers New Jersey Med- operative expectations, and that their goals and prefer- ical School, New York, NY. Jason Johanning, MD MS ences will be honored postoperatively. These systematic FACS, University of Nebraska Medical Center, Omaha, interventions facilitate the appropriate delivery of goal- NE. Tammy Bockman, MSN MHA RN, VA Nebraska- concordant treatments, and allow for the optimal Western Iowa Health Care System, Omaha, NE. Pierre deployment of limited palliative care resources. Lavedan, MD, Baylor Family Medicine Residency, Garland, TX. Susanne Walther, MSN ACNP-BC ACHPN, University Hospital, Montclair, NJ. Christine Boardingham, MEd CCC-SLP, University Hospital, The Language of Illness: The Art of Telling, Nutley, NJ Listening, and Self-Care Through Narrative Medicine (TH314) Objectives Melissa San Julian Mark, MD, Cincinnati Children’s Identify two emerging models for identifying the Hospital, Cincinnati, OH. Kristin Todd, MSW, Cincin- unmet palliative care needs of patients under nati Children’s Hospital Medical Center, Cincinnati, consideration for surgical interventions. OH. Daniel Todd, MA, Cincinnati State Technical Describe how trigger-based approaches can be and Community College, Cincinnati, OH. effective in changing the trajectory of care for pa- Objectives tients undergoing evaluation for surgical treatment. Define narrative medicine and explain how it can Describe the limitations of current common be used to enhance patient care. models for incorporating palliative care into the Describe various methods for practicing narrative surgical workflow. medicine both as a way to increase empathetic un- Consideration of surgical intervention often represents derstanding as well as to process one’s own expe- a crucial clinical crossroads for patients. Systematic trig- rience as a caregiver. gers for palliative care assessment and intervention in Demonstrate how the techniques of textual inter- this context can help ensure that important opportu- pretation (or ‘‘close reading’’) can help one culti- nities are not missed. These include directing the trajec- vate a broader and more nuanced perspective on tory of a patient’s care in a goal-concordant manner the lives of patients. 322 Schedule With Abstracts Vol. 53 No. 2 February 2017

Narrative has always been fundamental to the practice minute of heated humidified oxygen through a nasal of medicine, dating back to Hippocrates. Formalized cannula to maximize oxygenation. In addition to oxygen- in academia in the 1980’s through the work of Rita ation, HFOx may improve ventilation by reducing naso- Charon, narrative medicine is medicine practiced pharyngeal dead space, augmenting end-distending with narrative competence, which is the ability to pressure, reducing breathing effort by decreasing inspi- acknowledge, absorb, interpret, and act on the stories ratory resistance and increasing airway conductance, and plights of others. Narrative medicine has been decreasing the metabolic cost of breathing, and stimu- used to cultivate greater empathetic understanding lating the trigeminal and glossopharyngeal nerves in the physician-patient relationship, as well as to through a high-flow mechanism and the delivery of hu- help caregivers process their own experience. midified and heated gas. HFOx is currently used in the Stories are fundamental to our nature. Not only are we critical care, emergency room, post-operative, acute embedded in the stories that comprise our lives, but care, and to a certain extent, community care settings patient care also unfolds in story form. Carefully inter- to improve patient outcomes. Specifically, HFOx has preting the storied lives of patients is a critical compo- been found to improve survival compared to BiPAP nent of humane and competent medical practice. and regular oxygen in patients with acute hypoxemic res- Our team has adopted narrative practice as a tool for piratory failure, enhance ventilation in patients with self-care, particularly in response to secondary trauma. chronic hypercapenic respiratory failure, reduce the Our initial work has focused on trainees (residents need for reintubation in the post-operative setting, and and fellows) in Pediatric Hematology/Oncology who decrease apnea-hypopnea episodes among patients often have challenging experiences during their rota- with sleep apnea. We will summarize several prospective tions secondary to the acuity, emotional intensity, and clinical studies and randomized controlled trials that spe- exposure to death and dying. cifically examined the role of HFOx for the palliation of In this session, our interdisciplinary team will describe dyspnea. We will also discuss the practical aspects of deliv- our current use of narrative medicine to facilitate op- ering HFOx in the hospital and home settings, and some portunities for resident/fellow self-care and debrief- ethical considerations in using it at the end-of-life. We will ing. We will introduce theory, methods, tools, and end by discussing future research directions and how applications of narrative practice. In addition, we will HFOx can be delivered in routine care. The last 15 mi- share curricula, sample works, preliminary data and nutes of this session will involve active discussion. feedback about our current pilot program. We will also offer the opportunity for attendees to participate Clinical and Ethical Issues in Terminal in a brief narrative exercise. Gastrointestinal Dysfunction in Children with Severe Neurological Impairment High Flow Oxygen for Palliation of Dyspnea: (TH316) A State-of-the-Science Update (TH315) Jonathan Mullin, MD, Dana-Farber Cancer Institute David Hui, MD MS MSC, MD Anderson Cancer Cen- and Boston Children’s Hospital, Boston, MA. Robert ter, Houston, TX. James (Eddy) Jackson, RRT, MD An- Macauley, MD, University of Vermont, Burlington, VT. derson Cancer Center, Houston, TX. Objectives Objectives Review the etiology, evaluation and treatment for Review the pathophysiology of dyspnea and feeding intolerance in children with neurological mechanism of action of high flow oxygen. impairment. Provide an up-to-date the clinical evidence to sup- Formulate an approach to discussions surround- port the use of high flow oxygen. ing withdrawal of artificial hydration and nutri- Discuss the logistical and ethical considerations tion in children. when administering high flow oxygen for palliation. Explore ethical, legal and religious considerations Dyspnea occurs in approximately 10%-70% of cancer pa- in withdrawing artificial nutrition and hydration tients and is one of the most feared symptoms. It is asso- in children. ciated with decreased function, quality of life, and Children with severe neurological impairment survival. Few therapeutic options are available for dys- (SNI)dmany of whom are dependent on artificial pnea, mainly because it is under-researched. Contempo- nutrition and hydration (ANH)dare often deemed rary treatment with low-flow supplemental oxygen to have ‘‘disease progression’’ when they experience partially relieves the condition only in the minority of pa- refractory seizures, increased neurological disability, tients who are hypoxemic. In this presentation, we will or worsening respiratory status. This prompts a discuss high flow oxygen’s (HFOx) mechanism of action, reconsideration of the relative burdens and benefits evidence and practical applications for palliation of dys- of treatment and often leads to reevaluation of the pnea in cancer patients. HFOx delivers up to 60 L per overall goals of care. Vol. 53 No. 2 February 2017 Schedule With Abstracts 323

However, when these children experience feeding intol- independence, and sense of hopelessness are all asso- erance that is refractory to symptomatic management ciated with increased suicide risk. or modifications in the feeding regimen, it is often The overwhelming majority of suicides in the general not viewed in the same light. This is likely due to the population stems from treatable psychiatric condi- emotional resonance attached to feeding a person tions. Because of this, patients who attempt suicide (especially a child), the option of transitioning from are assumed to lack capacity; overriding their autono- enteral to parenteral nutrition and hydration (which mous wish for death by initiating invasive life-sustain- has its own set of burdens and benefits), and the ing treatments and detaining them against their will concern for pain and suffering caused by ‘‘starvation.’’ is considered ethically acceptable. This case-based session will explore this apparent Treating suicide attempts in patients with life-limiting inconsistency from clinical, ethical, religious, and illness poses an interesting ethical and clinical legal perspectives. Empirical studies on the symptom- dilemma. Unlike most people who attempt suicide, atic and prognostic implications of withdrawing these patients cannot be uniformly assumed to lack ca- ANH will be examined. Ethical consensus statements pacity. Rather, suicide at the end of life may be a on the role of ANH in serious and terminal illness rational approach to avoiding worsening functional sta- will be reviewed, with specific attention to whatdif tus and having some control over impending death. In anythingdmakes the pediatric context unique. The this framework, understanding how to compassionately significance of feeding in specific religious traditions care for patients with life-limiting illness who have at- (including the Roman Catholic Ethical and Religious tempted suicide or express suicidal ideation with intent Directive #58) will be examined. The role and applica- and plan becomes more complicated and nuanced. bility of federal and state lawdincluding the ‘‘Baby This presentation will help hospice and palliative care cli- Doe’’ regulationsdwill be explored. nicians identify risk factors for suicide in patients with life- We will argue that persistently refractory feeding intol- limiting illness, discuss core ethical principles informing erance may represent ‘‘terminal gastrointestinal medical decision making after a suicide attempt, and re- dysfunction’’ and can be considered an end-stage view both acute and long-term medical and psychosocial complication of SNI. As such, it should prompt a management of patients after a suicide attempt. reconsideration of the benefits and burdens of poten- tial treatments, as would disease progression in any Deprescribingdthe Who, What, When, Why, other organ systems. Withdrawal of ANH may be clin- and How (TH318) ically and ethically appropriate in such situations. Jennifer Pruskowski, PharmD BCPS CGP CPE, Univer- sity of Pittsburgh School of Pharmacy, Pittsburgh, PA. Mary Lynn McPherson, PharmD MA BCPS CPE, Uni- The Bridge Between Life and Death: versity of Maryland, Baltimore, MD. Holly Holmes, Attempted Suicide at the End of Life MD, UT Houston McGovern Medical School, Hous- (TH317) ton, TX. Neha Darrah, MD, Cedars-Sinai Medical Center, Los Objectives Angeles, CA. Jaime Goldberg, LCSW, Cedars-Sinai Describe the current prevalence of potentially Medical Center, Los Angeles, CA. Laura McVay, MSN inappropriate medications, or polypharmacy, in GNP-BC, Cedars-Sinai Medical Center, Los Angeles, patients with serious illness at the end of life. CA. Identify the appropriate population for Objectives deprescribing. Identify medical and psychosocial risk factors for Criticize the current literature base for suicide in patients with life-limiting illness. deprescribing. Discuss core ethical principles informing medical There are numerous evidence-based guidelines for the decision making for patients after an attempted initiation of drug therapy, however few to discontinue. suicide. This leaves an unbalanced equation for many patients Review acute management of patients including with life-limiting illnesses. Deprescribing is the system- initiation of artificial life support and establishing atic process of identifying and discontinuing drugs in code status. instances in which existing or potential harms outweigh Suicide is the tenth leading cause of death in the existing or potential benefits within the context of an in- United States and accounts for roughly 50,000 deaths dividual patient’s care goals, current level of func- per year. Less is known about suicide in patients with tioning, life expectancy, values, and preferences. It is life-limiting illness, but advanced disease and age are critical for palliative care clinicians to understand this known to be associated with increased suicide risk. process, and the evidence based literature surrounding Uncontrolled pain, cancer diagnosis, loss of this topic. This concurrent session will focus on the 324 Schedule With Abstracts Vol. 53 No. 2 February 2017

current prevalence of polypharmacy in patients with share specific group visit tools (i.e. patient booklets; life-limiting illnesses, the process of deprescribing, SMART goals worksheet; check-in sheets and tem- how to address barriers to deprescribing, model for im- plates to facilitate documentation/billing). Finally, plementation and the evidence regarding specific we will discuss the early experiences of ‘‘Planning for medication classes. We will highlight five commonly Future Medical Decisions via Group Visits’’ which was prescribed classes of medications that may be eligible named a Gold Status Practice in the VHA Undersecre- for deprescribing: anti-hypertensives, anti-diabetics, tary Shulkin’s Promising Practices Consortium and is anti-cholesterol medications, anticoagulants and ASA, being implemented at the Bedford Massachusetts and anti-dementia medications. This concurrent ses- VAMC. At the conclusion of the session, attendees sion will be focused for those clinicians practicing in will have practical guidance, techniques and tools for the palliative care setting, to target patients prior to hos- implementation of ACP discussions using group visits pice. in integrated (VA) or fee-for-service (Medicare) outpa- tient settings. ‘‘I Heard Something from Another Veteran’’: How to Use Group Visits to Engage Patients in Advance Care Planning (TH319) Paper Sessions Hillary Lum, MD PhD, University of Colorado and VA Eastern Colorado, Aurora, CO. Kimberly Garner, MD JD MPH FAAFP, Department of Veteran Affairs, Little A Provider-Based Quality Improvement Rock, AR. Charlie Antoni, LCSW ACHP-SW, Veterans Intervention Aimed at Increasing Affairs, Orlando, FL. Appropriateness of Radiation Therapy Objectives Regimens for Patients with Advanced Cancer Describe key components of advance care plan- and Painful Bone Metastases (TH320A) ning group visits. Anne Walling, MD PhD, University of California, Los Obtain person-centered tools and communica- Angeles, Los Angeles, CA. Phil Beron, MD, University tion skills to successfully facilitate advance care of California, Los Angeles, Los Angeles, CA. Neil planning group visits. Wenger, MD, University of California, Los Angeles, Discuss best practices for adapting and imple- Los Angeles, CA. Tania Kaprealian, MD, University menting advance care planning group visits. of California, Los Angeles, Los Angeles, CA. Susie Advance care planning (ACP) is a health behavior that McCloskey, MD MSHS, University of California, Los requires person-centered education, support by Angeles, Los Angeles, CA. Christopher King, PhD trained professionals and motivational strategies to MD, University of California, Los Angeles, Los An- promote goal-setting and actions. Group visits in the geles, CA. Kris Murrell-Diedric, MD, University of Cal- healthcare setting can effectively increase an individ- ifornia, Los Angeles, Los Angeles, CA. ual’s knowledge, motivation and self-efficacy. This ses- Objectives sion presents best practices and lessons learned from Understand appropriate radiotherapy regimens implementation of group visits focused on ACP in for painful bone metastases in patients with threeuniquehealthcaresettings(LittleRockVAMed- advanced cancer. ical Center [VAMC]; Orlando VAMC; University of Col- Understand an innovative approach aimed at orado Hospital). Over the past 5 years, we have increasing appropriateness of radiation therapy collectively engaged more than 3,900 Veterans and regimens for patients with advanced cancer and 120 Medicare beneficiaries in ACP discussions, deci- painful bone metastases. sion making, and documentation using group visits. Original Research Background. Although guide- To begin, we will provide an overview of the purpose, lines suggest that shorter course radiation treatments content, interdisciplinary team-based structure, pa- for patients with advanced cancer and painful bone tient population and recruitment strategies for group metastases are most appropriate, treatment patterns visit approaches, including strategies for adapting to in the United States are inconsistent with this particular healthcare settings. Next, we will describe approach. the person-centered impact of participating in ACP Research Objectives. We implemented a provider- groups, including increases in readiness and goal- focused intervention at a university-based radiation setting related to ACP, discussions with loved ones, oncology practice aimed at improving rates of short- designation of surrogate decision makers, and docu- er-course radiation treatments for patients with mentationinthemedicalrecord.Tomaximizeaudi- advanced cancer and painful bone metastases. ence engagement, we will invite discussion of Methods. The intervention involved key leaders of available evidence-based ACP patient resources and thepracticeparticipatinginaRAND/UCLA Vol. 53 No. 2 February 2017 Schedule With Abstracts 325

Appropriateness Panel to review the latest guide- Identify three areas of patient outcomes that can lines and evidence and judge appropriateness of be improved with the presence of social work various treatment regimens as it pertained to their evaluations. practice. These results were compared to current Original Research Background. As hospital based (7/2012-6/2013) practice patterns and presented palliative care teams strive to expand their interdisci- to the faculty group. This exercise informed a tem- plinary services, they are often tasked with providing plate-based point of care intervention led by a clin- outcomes data to justify additional staff. Research ical champion and leadership that focused on key highlighting improvement in patient outcomes can aspects of clinical and patient-centered care support the need for multiple disciplines within a including whether the bone metastases were compli- palliative care team. cated or uncomplicated, patient prognosis, extent of Research Objectives. The authors of this study disease, and travel distance for the patient to the aim to determine whether social workers impact treatment site. We compared rates of lower burden the risk of ICU admission, ICU death, and cardio- treatment regimens (less than 10 fractions) for 81 pulmonary resuscitation (CPR) events among hos- pre-intervention patients with 107 metastases pital decedents followed by a Palliative Care treated between 7/2012-6/2013 and 75 post-inter- practitioner. vention patients with 94 metastases treated between Methods. A retrospective chart review was done us- 5/2015-1/2016. ing data collected between January 1, 2010 and Results. Overall, painful bone metastases were February 29th, 2016 by the Pain and Palliative treated with less than 10 fractions more often in Care Department at the Queen’s Medical Center. the post-intervention period (38% v. 63%, The study population included hospitalized patients p<0.001). Uncomplicated bone metastases treated with cancer who were followed by the Pain and Palli- with conformal radiation were also more likely to ative Care service prior to any ICU transfer and ul- be treated with less than 10 fractions in the timately died in the inpatient setting. Charts were post- intervention period (19% v. 52%, p<0.001). evaluated for social work visits, ICU admissions, loca- One quarter of metastases were treated with tion of death, and CPR. SBRT during both the pre and post intervention Results. Of the 256 patients who met the inclusion periods. criteria, 196 patients were evaluated by social Conclusion. Leadership support, provider engage- workers. 11 of 196 (6%) who were seen by a social ment in integrating guidelines into practice, and a worker were later admitted to the ICU. Alternatively, note template with point of care clinical reminders 17 of 60 (28%) patients who had not received a so- can improve rates of appropriate, low-burden radia- cial work evaluation were admitted to the ICU. Social tion oncology treatments for patients with advanced work exposure between ICU admits and non-ICU ad- cancer. mits was statistically significant OR ¼ .1504 Implications for research, policy or practice. This (p<.0001). Similarly, risk of ICU death and presence strategy can be used to improve appropriateness of ra- of CPR was reduced among those who had social diation therapy. work intervention OR ¼ .1538 (p<.0001) and OR ¼ .2841 (p<.05), respectively. Conclusion. Incorporating social workers in the care of patients followed by the Palliative Care team is asso- The Impact of Social Work Encounters on ciated with a significant reduction in risk of ICU Risk of ICU Admission, ICU Death, and admission, ICU death, and CPR. CPR Among Hospitalized Patients with Implications for research, policy or practice. Cancer at End of Life (TH320B) Growth of interdisciplinary Palliative Care teams to Ivan Chik, MPH, University of Hawaii at Manoa, include a higher staffing ratio of social workers may John A. Burns School of Medicine, Honolulu, result in fewer ICU admissions at end of life. HI. Daniel Fischberg, MD PhD FAAHPM, John A Burns School of Medicine, Honolulu, HI. Ilan Bernstein, MD, University of Hawaii at Manoa, Factors Predicting Red Blood Cell John A. Burns School of Medicine, Honolulu, Transfusions at the End of Life in Cancer HI. Patients (TH320C) Objectives Jason Meadows, MD, Memorial Sloan-Kettering Describe the role of a social worker in an end-of- Cancer Center, New York, NY. Jessica Goldberg, MS life setting. MSN NP, Memorial Sloan Kettering Cancer Center, 326 Schedule With Abstracts Vol. 53 No. 2 February 2017

New York, NY. Raymond Baser, MS, Memorial Sloan Depression and Health Care Utilization at Kettering Cancer Center, New York, NY. End-of-Life Among Older Adults with Non- Objectives Small Cell Lung Cancer (TH320D) Identify 3 factors that predict increased RBC Cara McDermott, PharmD PhD, University of Wash- transfusion at end of life in cancer patients. ington, Fred Hutch, Seattle, WA. Scott Ramsey, MD Identify 3 factors that do not predict RBC transfu- PhD, Fred Hutchinson Cancer Center, Seattle, WA. sion at end of life in cancer patients. Aasthaa Bansal, PhD, University of Washington, Seat- Original Research Background. In many situations, tle, WA. Gary Lyman, MD MPH, Fred Hutchinson transfusions clearly improve longevity and/or quality Cancer Research Center, Seattle, WA. Sean Sullivan, of life (QOL). In terminal cancer patients the risk- PhD, University of Washington, Seattle, WA. benefit balance may sometimes be unclear. Objectives Research Objectives. We undertook this retrospec- Describe the prevalence of pre-existing depres- tive study to understand which non-laboratory factors sion in this population. may predict red blood cell (RBC) transfusion in the Characterize the relationship between pre-exist- last 7 days of life. ing depression, hospice and EOL services in this Methods. Between 10/1/2013 and 9/30/2015, 1248 population. in-patients with cancer died on medical oncology ser- Original Research Background. Depression is com- vices at our institution. The primary endpoint was mon among cancer patients. While research has number of RBC units received within 7 days before explored the association between psychological death. Predictors included patient sex, age, race, reli- distress during and after cancer treatment and use gion, state/country of origin, cancer diagnosis, inten- of high intensity end-of-life (EOL) care, there are sive care unit (ICU) death, length of stay (LOS), Do limited data available regarding depression existing Not Resuscitate status, chaplaincy visits, and palliative prior to a lung cancer diagnosis and health care utili- medicine consultation. Associations between the pre- zation at EOL. dictors and number of RBC units received were evalu- Research Objectives. To evaluate the association be- ated using zero-hurdle negative binomial models to tween depression occurring in the year prior to a diag- account for large numbers of patients who received nosis of stage 3B/4 non-small cell lung cancer zero RBC units. (NSCLC), hospice enrollment after diagnosis, and uti- Results. Patients were mostly Caucasian (73%), Chris- lization of emergency room (ER) services, hospitaliza- tian (58%), local residents (92% from NY/NJ/CT), and tion, and chemotherapy in the last 30 days of life. male (52%). Just under half (49%) were seen by pallia- Methods. We used the Surveillance, Epidemiology, tive medicine within 7 days before death. Thirty-eight and End Results (SEER)-Medicare database with percent received 1-6 RBC units and 3% received 7 or claims from 2007-2013. We identified subjects with more units (range 7-23) within 7 days before death. depression using International Classification of Dis- In the multivariable model, patients with leukemia, lym- eases, version 9 (ICD-9) codes and prescriptions for phoma, myeloma, and genitourinary cancers were antidepressants from the Medicare Part D claims file. significantly more likely to receive RBC transfusion. Results. Subjects with pre-existing depression ICU death predicted both receipt of RBC transfusion (n¼2082, 14%) were more likely to be female, unmar- (OR¼4.7) and higher number of units received ried, white, Medicaid-eligible, and have higher comor- (RR¼1.5). Female sex was associated with receiving bidity scores compared to 12,303 subjects (86%) transfusion (OR¼1.6). In unadjusted analysis, patients without depression. Accounting for competing risk who had a palliative medicine consultation were less of death, depressed subjects were more likely to enroll to likely to receive a transfusion (OR¼0.72) and tended in hospice care (subhazard ratio 1.19, 95% confidence to receive fewer units (RR¼0.72), but this was not signif- interval (CI) 1.09-1.30) and less likely to die in hospi- icant in multivariable analysis. tal (adjusted odds ratio (AOR 0.79, 95% CI 0.65-0.97). Conclusion. Sex, cancer type, and ICU death seem to We found no association between pre-existing depres- influence end-of-life (EOL) transfusions whereas race, sion and ER services (AOR 0.91, 95% CI 0.77-1.07), religion, and state/country of origin do not. Palliative inpatient admission (AOR 1.06, 95% CI 0.90-1.25), consultation may reduce RBC transfusion at EOL for or chemotherapy (AOR 0.84, 95% CI 0.68-1.05) in some patients but more research is needed to identify the last 30 days of life. subgroups most impacted. Conclusion. Older adults with depression prior to a Implications for research, policy or practice. diagnosis of advanced stage NSCLC were more likely Research assessing transfusions and longevity/QOL to utilize hospice services compared to those without at EOL are needed. depression, were less likely to die in the hospital, Vol. 53 No. 2 February 2017 Schedule With Abstracts 327

and were no more likely to use high-intensity EOL not returning to a ‘‘normal’’ body and grieving an care. imagined post-transplant life. Implications for research, policy or practice. As Implications for research, policy or practice. depressed subjects were more likely to use hospice Grief is a multidimensional experience that affects care, hospice providers may need additional support cognitive, spiritual and physical functioning. Clinical to meet mental health needs in this population. recognition, observance, and therapeutic presence in patient grief is ideal. For future research: validation Grieving or Getting Stuck: When LVAD Does of generalizable grief findings is needed and explora- Not Progress to Heart Transplantation tion of common and atypical grief’s impact on deci- (TH321A) sion-making is recommended. Megan Morrison, PhD ARNP ACHPN, University of Washington School of Nursing, Seattle, WA. Barbara B. McGrath, PhD RN, University of Washington School of Nursing, Seattle, WA. Megan L. Morrison, What’s in the ‘‘Black Box’’? Describing the PhD RN ARNP ACHPN, University of Washington Focus of Early, Outpatient Palliative Care School of Nursing, Seattle, WA. Consultation Evaluations and Treatment Objectives Recommendations for Individuals with List the three LVAD device strategies and recog- Advanced Heart Failure (TH321B) nize the prevalence of clinical reclassification. Rachel Wells, MSN RN, University of Alabama at Bir- Describe the grief and loss that was found in this mingham, Birmingham, AL. Deborah Ejem, PhD, study’s participants. University of Alabama at Birmingham, Birmingham, Original Research Background. Left ventricular AL. James Dionne-Odom, PhD RN, School of Nursing, assist devices (LVADs) can be used as (a) bridge to University of Alabama at Birmingham, Birmingham, heart transplant, (b) destination therapy, or (c) bridge AL. Gulcan Bagcivan, PhD, School of Nursing, Univer- to evaluation for transplant candidacy. Patients with sity of Alabama at Birmingham, Birmingham, AL. LVADs are known to transition between these classifi- Konda Keebler, MS BSN RN, University of Alabama cations and some unexpectedly find themselves with at Birmingham, Birmingham, AL. Jennifer Frost, MS an LVAD for the remainder of their life when heart RN, University of Alabama at Birmingham, Birming- transplant becomes unequivocally not an option. ham, AL. Elizabeth Kvale, MD, University of Alabama at Birmingham Center for Palliative and Supportive Research Objectives. This analysis came from unex- Care, Birmingham, AL. Marie Bakitas, DNSc NP-C pected findings in a qualitative study on the process of FAAN, University of Alabama at Birmingham, Bir- decision making in patients who have an LVAD for mingham, AL. destination therapy. In the interview guide, there were no questions in regards to heart transplant, but Objectives the participants consistently and spontaneously dis- Describe evaluation and treatment recommenda- cussed complicated thoughts and feelings about not tions in a protocol driven outpatient palliative being listed for transplant. care consultation for patients with advanced heart Methods. failure. Semi-structured interviews conducted be- tween June 2015 and December 2015 with 11 partici- Consider implications of study results for future pants who had LVADs for DT. The average age of outpatient heart failure care. the participants was 67, with 10 males and one female. Original Research Background. Little has been re- Median time from implantation of the LVAD to inter- ported about the focus of outpatient palliative care view was 3.7 years (range: 1.17-7.25). Two participants consultation (OPCC) for persons with advanced heart resided in skilled nursing facilities. failure (HF) enrolled in a trial of early palliative care Results. Grief and loss around not getting a heart (EPC). transplant were core themes. Sub-themes including Research Objectives. To describe evaluation prac- (a) taking in the news, (b) adjusting to this body, (c) tices, treatment recommendations, and regional varia- no longer jumping through hoops, (d) mistrust, (e) tion of protocol-driven OPCCs for advanced HF EPC the hypothetical transplant, and (f) hope. trial participants. Conclusion. Participants in this study described a lot Methods. Qualitative content analysis of protocol- of loss. On the one hand there is the defined loss of driven OPPC notes of NYHA Class III/IV patients per- not progressing to a heart transplant, but the loss of formed during the ENABLE CHF-PC: Educate, transplant also yields a chronic loss for this group of Nurture, Advise, Before Life Ends; [4/1/14-8/31/ 328 Schedule With Abstracts Vol. 53 No. 2 February 2017

15]) EPC pilot trial conducted at two sites located in Methods. In a cross-sectional mixed methods study, the North- and Southeast. self-care was measured quantitatively in both partners Results. Of 61 ENABLE CHF-PC participants, 39 with the Self-care of Heart Failure Index (SCHFI) (64%) had an OPCC (Northeast site, n¼27; South- comprised of maintenance (day to day care), manage- east site, n¼12), averaging 60 minutes in duration. ment (symptom evaluation and response), and self-ef- Symptoms most frequently evaluated were mood ficacy scales and a similar caregiver version. Scores (n¼35, 90%), dyspnea (n¼28, 72%), and chest were dichotomized- $70 adequate; # 69 inadequate; pain (n¼24, 62%). General care planning and social joint qualitative interviews were conducted, tran- history areas most frequently assessed were history of scribed verbatim and underwent content analysis. close relationships (n¼35, 90%), family support Data integration involved information matrices for (n¼33, 85%), advance directive/code status (n¼33, within/across-case analyses. 85%), and functional status (n¼30, 77%). Treatment Results. In 27 dyads (n¼54), the average patient was recommendations focused on care coordination 77 year old, male with a 64 year old caregiver (primar- (n¼13, 33%) and specialty referrals (n¼12, 31%). ily spouse (n¼15) or female adult child (n¼9)). Mean Between-site OPCC evaluation differences were as- scores on SCHFI maintenance, management, and self- sessing family support (Northeast vs. Southeast site: efficacy scales were inadequate (range ¼ 54-68) for 100% vs. 50%, p¼0.007), code status (96% vs. 58%, both. Dyads engaged in self-care according to life p¼0.03), goals of care (89% vs. 41.7%, p¼0.01), course patterns (‘‘we do everything together because that’s and prognosis understanding (85% vs. 33%, the way we are’’); and/or according to whether it was p¼0.08). Treatment recommendation differences maintenance (‘‘I go through my routine. I weigh myself.’’); were most pronounced for care coordination or management (in response to symptoms, the previ- (40.7% vs. 17%, p¼0.11). ous person responded, ‘‘We usually call right away’’); Conclusion. OPCCs for HF primarily focused on and/or by mobilizing the help of another (‘‘I called evaluating symptoms (mood, dyspnea, chest pain), my sister.’’). Dyads, where the patient or caregiver relationship history, caregiver/family support, scored $ 70 on self-efficacy and/or management, advance directive/code status, functional status, and kept their maintenance (day-to-day care) pattern on recommending care coordination and referrals. despite the patient’s increased symptoms. However, Considerable regional differences in OPCC practices dyads scoring # 69, were more likely to mobilize help. may be attributable to site differences in OPCC docu- Conclusions. We have identified an opportunity to mentation templates. enhance self-care by assessing for patients’ and care- Implications for research, policy or practice. Use givers’ dyadic patterns. of uniform documentation templates based on Na- Implications for research and practice. Managing tional Consensus Guidelines, may ensure that community-dwelling adults with HF needs to involve OPCCs for HF patients are comprehensive and stan- identifying life course patterns in self-care and supple- dardized. menting inadequate self-care patterns as needed with outpatient palliative care services. We Work It Out Between Us: Identifying Opportunities to Enhance Heart Failure Primary Results from the Collaborative Care Self-Care in Community-Dwelling Patients to Alleviate Symptoms and Adjust to Illness and Informal Caregivers (TH321C) in Heart Failure (CASA) Randomized Harleah Buck, PhD RN FPCN FAAN, Penn State Her- Clinical Trial (TH321D) shey Medical Center, University Park, PA. David Bekelman, MD MPH, University of Colorado Objectives Denver, Denver, CO. Larry Allen, MD MHS, University Describe and differentiate the three HF self-care of Colorado School of Medicine, Aurora, CO. Brack concepts e self-care maintenance, self-care man- Hattler, MD, Denver VA Medical Center, Denver, CO. agement, self-care self-efficacy. Edward Havranek, MD, Denver Health Medical Cen- Assess for life course patterns of self-care in older ter, Denver, CO. Diane Fairclough, DrPH, University adults with HF. of Colorado, Aurora, CO. Connor McBryde, MD, Uni- Original Research Background. Understanding versity of Colorado Denver, Denver, CO. Paula Meek, how patient and informal caregiver dyads mutually PhD RN, University of Colorado, Aurora, CO. engage in heart failure (HF) self-care is imperative Objectives to the delivery of quality outpatient palliative care. Describe the outcomes of a randomized clinical Research Objectives. To examine dyadic HF self- trial that tested the effect of a palliative and psy- care. chosocial care intervention in heart failure. Vol. 53 No. 2 February 2017 Schedule With Abstracts 329

Discuss the implications of the findings from the 1:30e2:30 pm clinical trial, using data from the population enrolled, the outcome measures, and the Concurrent Sessions intervention. Background. Many people with heart failure (HF) The Practice of Palliative Medicine in suffer from poor health status (heavy symptom Developing CountriesdPart One (TH330) burden, reduced functional status and quality of Anuja Damani, MD, Tata Memorial Hospital, Mahara- life). Depression is strongly associated with health sta- shtra, India. Rubayat Rahman, MD, Bangabandhu tus in HF. Sheikh Mujib Medical University, Bangladesh. Layth Objective. Determine whether a palliative and psy- Mula-Hussain, MB ChB CCI MSc JB EF, Zhianawa Can- chosocial care intervention improves health status in cer Center, Sulaymaniyah, Kurdistan, Iraq. HF. Objectives Learn how physicians in specific countries pro- Methods. The CASA randomized clinical trial vide palliative care to their patient populations compared the CASA intervention to usual care. often with limited resources. The CASA intervention included a nurse who Understand specific cultural and political chal- managed symptoms (shortness of breath, fatigue, lenges to developing palliative care clinical, pain) and a social worker who provided psychoso- educational and research programs. cial care. Patients were reviewed weekly with a pri- Describe roles of different health care providers mary care provider, cardiologist, and palliative practicing palliative care and how they meet the care physician. Patients with HF and poor health needs of their local populations. status were enrolled from a VA, academic health Please join AAHPM’s International Scholars for a system, and urban safety net hospital. The primary panel discussion. Each scholar will present for 10-15 outcome was HF-specific health status, measured minutes on the state of the practice of palliative care using the Kansas City Cardiomyopathy Question- in their home country, with an emphasis on the roles naire (range, 0-100), at 6 months. Secondary out- of physicians, nurses, and other healthcare providers; comes included depression (Patient Health the status of education and research in the field; Questionnaire-9), overall symptom distress (Gen- and the unique challenges facing patients and pro- eral Symptom Distress Scale), specific symptoms viders. There will be time allotted after each presenta- (PEG pain, PROMIS fatigue, shortness of breath) tion to field questions and dialogue from the and mortality. audience. Prepare to be educated and inspired by Results. 314 patients were randomized (157 inter- these accomplished individuals who are leading and vention, 157 control). Participants were generally advancing the field of hospice and palliative medicine male (77%) and white (63%), and the mean age in their countries of origin. was 65.5 years. 57% had reduced ejection fraction. At 6 months, mean KCCQ score improved 5.5 points in the intervention arm and 2.9 points in the control A Rising Tide Lifts All Boats: the Palliative arm(difference,2.7;95%CI-1.3,6.6;p¼0.19). Care Research Cooperative (PCRC) as a Among secondary outcomes, depressive symptoms Resource to Improve the Science of Palliative and fatigue improved at 6 months with CASA (effect Care (TH331) Jean S. Kutner, MD MSPH FAAHPM, University of Col- sizes of -0.29 and -0.30, respectively, p¼0.02 for orado School of Medicine, Aurora, CO. Krista Harri- both). There were no changes in overall symptom son, PhD, University of California San Francisco, San distress, pain, or shortness of breath. Mortality at Francisco, CA. Christine Ritchie, MD FAAHPM, Uni- 12 months was similar (CASA, 10/157; usual care, versity of California San Francisco, San Francisco, 13/157; p¼0.52). CA. Betty Ferrell, PhD MA RN FAAN FPCN, City of Conclusion. This multisite randomized trial of the Hope National Medical Center, Duarte, CA. Jon P. Fu- CASA intervention did not demonstrate improved runo, PhD, Oregon State University, Portland, OR. HF-specific health status. Depression and fatigue Thomas LeBlanc, MD MA, Duke University School improved. of Medicine, Durham, NC. Kathryn Pollak, PhD, Implications. Alternate or more intensive interven- Duke University, Durham, NC. tions should be evaluated to improve health status in Objectives HF. This study raises questions about the link between Summarize how the Palliative Care Research depression and health status in HF. Cooperative Group (PCRC) can improve the 330 Schedule With Abstracts Vol. 53 No. 2 February 2017

evidence base of palliative care and end-of-life Cincinnati, OH. Rachelle Bernacki, MD MS clinical practice. FAAHPM, Dana-Farber Cancer Institute, Boston, MA. Distinguish how the PCRC can facilitate the appli- Objectives cation and conduct of large multi-site trial testing List the current challenges of advance care plan- the dissemination of a palliative care intervention. ning (ACP) documentation within electronic Assess how the PCRC supports investigator devel- health records (EHRs). opment, especially for those outside of traditional Identify pearls and pitfalls of ongoing efforts to academic settings. design EHR systems that support recommended The Palliative Care Research Cooperative Group practices, including entry, review and retrieval of (PCRC) was established in 2010 with generous grant ACP-related information. support from the National Institute of Nursing Describe key EHR design elements that promote Research to improve the evidence base for palliative the accessibility of advance directives in electronic care practice. The PCRC is a first-of-its-kind group in health records. the U.S., yet many palliative care clinicians and inves- The new Centers for Medicare and Medicaid Services tigators are unaware of its remarkable resources and (CMS) rule to reimburse for advance care planning the opportunities it provides. Increasing overall aware- (ACP) may result in more conversations in the clinic, at ness about the PCRC and its importance is critical for the bedside, and at home. The recent ‘‘Dying in America’’ palliative care practice. The PCRC has created a com- report recommended that comprehensive care should munity of palliative care clinicians and researchers ‘‘include coordinated, efficient, and interoperable infor- who engage in research discovery via an infrastructure mation transfer across all providers and settings and be that supports investigators who seek to improve the consistent with individuals’ values, goals, and informed quality and delivery of palliative and end-of-life care. preferences.’’ A recent survey of physicians found that This multi-institutional, multi-disciplinary panel will illus- only 60% said that their electronic medical record had a trate how investigators are utilizing the PCRC’s infrastruc- specific location for advance care plans and one third ture to improve the quality of their methods and relayed that their EHR does not display content of the capabilities, as a roadmap for other current and future in- ACP conversations. Palliative care clinicians need to drive vestigators to partner with the PCRC to improve the palli- EHR modification to promote timely and accurate docu- ative care evidence base. Drs. Kutner and Ritchie, mentation, review and retrieval of ACP information across physician-researchers and co-leaders of the PCRC, will sites of care. begin by outlining the need for the PCRC, its history, In this interactive interdisciplinary session, we will and the resources it provides to help investigators design, address standards and best practices necessary for fund, and conduct their studies. Dr. Ferrell, a nurse- advance care planning documentation in the EHR. researcher, will use her funded study of a multi-site palli- First, we will review the challenges of ACP documenta- ative care intervention to provide further examples of tion within and across health care settings in an envi- what resources are available to support high-quality clin- ronment of competing EHR systems. We will then ically-relevant research. Dr. Pollak, PCRC co-lead, and Dr. discuss the pearls and pitfalls of ongoing efforts to Ritchie will then describe three ways that PCRC supports design EHR systems that support recommended ACP the development of investigator knowledge and skills in practices. Lastly, participants will be able to identify palliative care and end-of-life research, including a discus- key design elements for the optimization of their sion of the PCRC ‘‘cores’’ and resources (for example, own EHRs in advance care planning. investigator development, caregiver research, etc.). Finally, Drs. Furuno, Harrison, and LeBlancdrespec- tively an epidemiologist, health services researcher, and Designing a Staffing Model to Support physician-researcherdwill discuss how findings and Productivity and Flexibility Among Billable experience from PCRC-funded investigator development Providers (TH333) Jessica S. Heintz, MD FAAHPM, Inova Health System, pilot studies are being leveraged into career development Fairfax, VA. Lynn H. Spragens, MBA BA, Spragens & and independent research opportunities. Associates LLC, Durham, NC. Mary S. Wheeler, MSN FNPC RN ACHPN, Inova Fairfax Hospital, Fairfax, VA. After the Conversation: Designing an Objectives Electronic Health Record for Dynamic Discuss the mechanics of RVU derivation, and Advance Care Planning (TH332) how to use the ‘‘conversion factor’’ to predict Irene M. Yeh, MD MPH, Dana-Farber Cancer Institute, RVU generation based upon ranges of volume Boston, MA. Eliza Shulman, DO MPH, Atrius Health, and use of billable staff. Needham, MA. Jennifer Hester, DNP AOCNS-BC Utilize transparency in RVU data reporting to ACHPN, The Christ Hospital Health Network, help manage interdisciplinary team performance Vol. 53 No. 2 February 2017 Schedule With Abstracts 331

and effective use of IDT members to maximize ongoing substance abuse issues while promoting flexibility in delivery of patient care. opioid safety. Build leadership credibility and improve support Formulate conflict resolution model to promote for palliative care staff by demonstrating compe- comprehensive, longitudinal care between pro- tence in managing wRVU data. vider and patient; mitigate provider and patient One of the most challenging aspects of administrative distress; and develop advocacy strategies for this leadership of palliative care teams is understanding vulnerable patient population. and utilizing fiscal awareness and predictive modeling Caring for patients with recent or concurrent substance to staff appropriately for anticipated patient volume use, opioid dependence, and opioid diversion remains changes. While the larger movement in health care one of the most challenging sub-populations that Hos- has been toward ‘‘value based health care’’ balancing pice and Palliative Medicine providers face. Meanwhile, safety, quality, and satisfaction with costs, pressures on a national level, the number of deaths due to over- on the physician workforce continue to focus on vol- doses from drugs, including prescription medications, ume driven productivity typically measured by RVU has quadrupled in recent years. This increase in drug- generation. While RVU production should not be related deaths has led to increased scrutiny on the num- the primary marker of value for providers, particularly ber of opioid prescriptions prescribed annually, sources in palliative care, a detailed understanding of the util- of prescription opioids being used for non-medical pur- ity, mechanics and language surrounding RVUs is poses, and the role that physicians may have in inadver- essential to leading, managing, and growing a pallia- tently contributing to the epidemic. As a result, there has tive care team, in order to effectively negotiate with been a call for the provision of increased educational re- administrative leadership for programmatic needs. sources and prescriber guidelines to aid providers in Most palliative care team leaders do not have specific making informed prescribing decisions and reduce the training in the financial aspects of provider billing, over-prescribing of opioids. However the institution of revenue prediction and management of staffing in such guidelines, often with conflicting recommenda- the context of productivity pressures. Understanding tions, is not sufficient to equip current Hospice and how to reason through revenue offset of program- Palliative Medicine practitioners with realistic models matic costs and implications for staff recruitment is by which to address issues of substance use, opioid essential for determining staffing optimization. In dependence, and opioid diversion in patients who are this concurrent session participants will learn from a actively experiencing symptomatic burden from their palliative care team’s journey through business plan- potentially life-limiting illnesses. ning, and staff increases based upon volume targets Utilizing summaries of recent evidence, case and successful revenue capture. studies, and discussion, this concurrent session Through sample cases and guided discussion, this ses- aims to present a practical framework for providers sion will provide insight into developing effective to build upon to address these complex issues coping strategies within an RVU focused world. At- within their own practice. Key areas of focus will tendees will learn how to predict, adjust and adapt include normalizing discussions about sensitive as- team models to meet growth needs, while balancing pects of history-taking; standardizing intake infor- reality of productivity mandates. Participants will mation to improve identification of patients at receive access to an RVU calculator and review income high-risk for opioid dependence; and building statements for a palliative care team. communication strategies to enhance trust, pro- mote patient engagement, and negotiate conflict When the Apple Falls Far from the Tree: A within the clinical encounter. Finally, presenters Systematic Approach to Providing Quality will share their personal experience with devel- Care for Patients at High-Risk for Opioid- oping timeframes to carry out action plans, efficacy Dependence (TH334) of such action plans, and methods by which action Nelia Jain, MD, Rush University Medical Center, Chi- plans have been re-evaluated, resulting in either cago, IL. Erin L. Bagwell, LCSW, Rush University Med- continuation of care or identification of alternate ical Center, Chicago, IL. Sean O’Mahony, MD MS, routeofcareprovision. Rush University Medical Center, Chicago, IL. Objectives Courageous Conversations: Using Interactive Define a systematic approach to identify patients Games to Discuss Goals of Care and with recent or current substance abuse, opioid- Advance Care Planning with Adolescents dependence, and diversion. and Their Families (TH335) Propose a framework utilizing multi-disciplinary Tessie W. October, MD, Children’s National Health modalities to create action plans that address Systems, Washington, DC. Lori Wiener, PhD, National 332 Schedule With Abstracts Vol. 53 No. 2 February 2017

Cancer Institute and National Institute of Health, Be- ‘‘I Understand There’s A New Law...’’: thesda, MD. Responding to Patient Inquiries About Objectives Physician-Assisted Dying (TH336) Briefly review state-of-the art, evidence-based in- Gregg VandeKieft, MD MA FAAHPM, Providence St. terventions to support advance care planning Peter Hospital, Olympia, WA. Eric Widera, MD for teens in order to promote patient-centered FAAHPM, University of California San Francisco, San care. Francisco, CA. Vyjeyanthi Periyakoil, MD, Stanford Introduce 3 interactive, play-based tools to facili- University School of Medicine, Palo Alto, CA. Denise tate adolescent patients’ participation in goals of Hess, MDiv, Kaiser Permanente, Rancho Palos Verdes, care and advance care planning discussions for CA. end-of-life care. Objectives Practice beginning the advance care planning dis- Describe the history and regulatory framework of cussion using an advance care planning tool, legalized PAD in the US. Voicing My Choices. Identify the primary concerns expressed by pa- Including adolescents in advance care planning has tients who inquire about PAD. been identified by the Institute of Medicine as a stan- Identify individual provider and team biases dard designed to promote patient-centered care. Un- (moral, ethical, affinity, confirmational), attitudes fortunately, adolescents don’t always get a seat at the and assumptions about PAD and patients who table. This exclusion often occurs because providers request PAD. are uncomfortable and unprepared to initiate these Currently, one in six Americans live in a jurisdiction important discussions, adolescents frequently want to where physician-assisted dying (PAD) is legal. Most protect their parents and won’t volunteer to be persons who inquire about PAD will ultimately not included, and parents are often afraid to talk about choose it. This session will present a brief overview death with their child. We know from our research, of the current experiences with PAD in the US and and that of other scientists, that adolescents want to highlight practical medico-legal points related to engage in these conversations and they can partici- PAD. Next, using three interactive cases, we will eluci- pate. Also, parents report less decisional regret and date the common challenges in communicating effec- psychosocial long term outcomes when their child tively with patients and families requesting PAD. The participated in advance care planning decisions. primary focus will be the clinician’s response to any In this workshop we aim to introduce 3 tools designed patient or family member who inquires, regardless of to engage adolescent patients in the discussion. the clinician’s personal political or ethical views ShopTalk: a therapeutic game, created to help youth regarding PAD or the patient’s intent to actually follow living with cancer talk about their illness in a non- through with it. The cases will help elicit a deeper un- threatening way with a health care provider. derstanding of the concerns or motivations prompting Jenga: a game that uses stacked wooden blocks in- inquiries about PAD, with the goal of comprehensively scribed with thought-provoking questions that addressing multi-dimensional suffering and fostering encourage discussion about goals of care and advance delivery of the best care possible for vulnerable indi- care planning. viduals. We will use short interactive role play exercises My Gift of Grace: a conversation card game. 74% of to promote a deeper understanding of the common people who played My Gift of Grace went on to challenges in responding effectively to requests for perform an advance care planning activity following PAD. the game. We will first introduce each of the tools then invite How Do We Chart a New Course for a participants to practice in a small group, rotating System in Crisis? A Multi-Center, Regional through all 3 tools. After the small groups practice Collaborative to Improve Supportive each tool, we will report our experiences to the large Oncology Care (TH337) group as a whole. Finally, participants will be broken Catherine Deamant, MD, JourneyCare, Glenview, IL. into triads (patient/family member/health care Shelly Lo, MD, Cardinal Bernardin Cancer Center, provider) to practice through role-play how to intro- Maywood, IL. Amy Scheu, MSH CHPCA, Advocate duce advance care planning with patients and their Healthcare, Chicago, IL. James Gerhart Rush Univer- families. sity Medical Center, Chicago, IL. Dirk Labuschagne, Vol. 53 No. 2 February 2017 Schedule With Abstracts 333

MDiv, Cook County Health and Hospitals System, Chi- This year in review focuses on patient- and systems-level cago, IL. research that impact the delivery of palliative care to old- Objectives er adults receiving long-term services and supports Define a structure to address gaps in supportive (LTSS), including institutional care. Functional and oncology care. cognitive impairment are very common in older adults Describe initiative work that addresses gaps and receiving LTSS. This patient population also has multi- needs in supportive oncology care. ple chronic conditions, which are associated with high Appraise the resources developed to impact sup- symptom burden. For example, among older adults portive oncology quality. with heart failure, 50% have 5 or more chronic condi- This concurrent session will describe a regional collab- tions. High symptom burdens are associated with greater oration to improve supportive oncology care across a use of healthcare, higher risk of nursing home admis- large metropolitan area. Funded by the Coleman sion, and lower quality of life. Foundation, the initiative focused on strategies to The purpose of this presentation is to identify and review implement recommendations by Institute of Medicine recent research focusing on palliative care of older adults (IOM) 2013 Report, Delivering High Quality Cancer receiving LTSS, and guide the audience in applying the Care: Charting a New Course for a System in Crisis. During literature to their patients and to the systems of care in the session we will provide an overview of a multi- which they treat patients, using practical takeaways. The center multi-disciplinary supportive oncology collabo- settings of interest are the entire continuum of care rative, which included academic, community and ranging from the community to assisted living to the safety net healthcare organizations focused on identi- nursing home, as well as acute and subacute care. The fying supportive oncology gaps and needs and identi- presenters utilize a modified Delphi method of screening fying strategies for improving delivery of care. Three and choosing publications that may impact the delivery of design teams focused on various aspects of supportive interdisciplinary palliative care over the coming year. oncology, including distress; survivorship; and pallia- The three symposium presenters bring their diverse tive care/hospice. We will present the supportive expertise to the presentation. Dr. Unroe is the project oncology screening tools (paper and electronic director of a CMS clinical demonstration project, version) that will be available for public use, provide OPTIMISTIC (Optimizing Patient Transfers, an overview of brief and practical reference docu- Improving Medical Quality, Impacting Symptoms: ments that were developed to guide further evaluation Transforming Institutional Care). Dr. Ersek has con- or intervention resulting from the screening tool ducted several funded studies focused on older adults, assessment, and development of National Compre- particularly those living in nursing homes and those hensive Cancer Network (NCCN) endorsed webinar with dementia. Dr. Messinger-Rapport is a geriatric training modules on key supportive oncology topics. and palliative care physician and clinical educator A panel discussion representing multiple disciplines with an emphasis on long-term care. and stakeholders involved in the initiative will provide perspective and insight about the opportunities and challenges of this large, regional initiative and lessons I Know It’s Early but Can I Get a Refill on learned. My Pain Medicines? How to Identify and Manage Chemical Coping in the Cancer Geriatric Palliative Care: From Bench to Patient (TH339) Bedside and Back in 2017 (TH338) Eric Prommer, MD HMDC FAAHPM, Greater Los An- Barbara Messinger-Rapport, MD FACP, Hospice of the geles Healthcare, Los Angeles, CA. David Hui, MD MS Western Reserve, Cleveland, OH. Mary Ersek, PhD RN MSC, MD Anderson Cancer Center, Houston, TX. FPCN, University of Pennsylvania, Philadelphia, PA. Egidio Del Fabbro, MD, Virginia Commonwealth Uni- Kathleen Unroe, MD MHA, Indiana University, Indi- versity, Richmond, VA. Rony Dev, DO, University of anapolis, IN. Texas and MD Anderson Cancer Center, Houston, TX. Objectives Objectives Review high quality palliative care research from Learn comprehensive assessment of decreased 2016 that focuses on older adults. opioid efficacy in the cancer patient. Discuss the opportunities and challenges of Learn the concept of chemical coping and distin- applying this research to the care of older adults guish it from addiction. with life-limiting illness. Learn how to screen for chemical coping. Identify practical takeaways to implement change The typical cancer patient experiences both a physical in clinical practice and system of care of older and emotional onslaught. Opioids have proven efficacy adults with palliative care needs. in the management of cancer pain. When patients 334 Schedule With Abstracts Vol. 53 No. 2 February 2017

require escalating doses of opioids without adequate Methods. The course took place at a simulation cen- pain relief, a differential diagnosis is generated. This ter supporting a large healthcare system. All curricular list includes disease progression as well as examining is- items, surveys, and tests were pilot tested. The course sues in the psychological, social, and spiritual dimen- included pre-course exposure to the discussion guide sions. The list of diagnostic considerations should and a video demonstration, 2.5 hours of didactic con- now include delirium, somatization, depression, and tent, and 4 simulations with actors playing patients. chemical coping. Chemical coping is defined as ‘‘the Knowledge was tested with 24-question pre-post multi- use of opioids to cope with emotional distress, charac- ple choice question (MCQ) test. A pre-post-delayed terized by inappropriate and/or excessive opioid (30 to 90 days) survey of learner confidence across 6 use’’. Patients exhibiting chemical coping often have content areas was analyzed with a linear mixed effects a prior history of alcoholism or substance abuse, and model. may require higher doses of opioids like patients with Results. 69/83 individuals consented to participate addiction histories. It becomes important to recognize during 7 courses over 13 months ending May 2016, that a ‘‘chemical coper’’ may exhibit a broad spectrum including 43 nurses, 16 social workers, and 10 others. of behavior that can range from harmless misuse of Pre-Post MCQ scores improved from 83%10 to opioid to true addictive behavior. Where this patient 92%8(p< 0.001). Paired surveys of self-confidence truly exists on the spectrum may determine interven- were available for 65, 65, and 40 learners respectively tions needed. Accurate identification of the chemical with combined scores of 5.42.8 pre, 7.61.9 post, coper may prevent extremes of opioid therapy such and 8.11.8 delayed on a 10 point scale. (Pre-Post, as unnecessary opioid dose escalation and opioid p< 0.001) (Pre-Delayed, p < 0.001). Self-perceived adverse effects or perhaps undertreating a patient competence with advance directives improved with requiring high-dose opioids for pain control. This ses- 48% pre, 86% post, and 92% delayed choosing ‘‘min- sion will focus on strategies to manage patients exhibit- imal supervision’’ or ‘‘independent’’ on a 4 category ing chemical coping. By means of clinical case scale (rank-sum chi2 (2df) ¼37.90, p < 0.001). De- presentations and examination of the literature the ses- layed surveys indicated 20/40 conducted ACP. Of con- sion will: 1.) Review the causes of decreased opioid ef- sented individuals with logging data 28/58 went on to ficacy in the cancer patient; 2.) Identify characteristic conduct 806 ACPs (mean 2.2/month/facilitator, me- features of the chemical coper and distinguish them dian 0.0/month/facilitator), with a skewed distribu- from pseudo-addiction and addiction; 3.) Identify com- tion due to several individuals given ACP as a core plications of chemical coping; 4.) Identify methods of job role. screening for chemical coping; 5.) Identify and make Conclusion. Knowledge and self-perceived confi- recommendations with respect to risk mitigation strate- dence and competence improved with training, with gies for chemical copers. half of learners going on to conduct ACP in practice. Implications for research, policy or practice. Future research will focus on success measured by pa- Paper Session tient centered outcomes. Health systems need to consider training resources and job support to pro- Outcomes of an Actor-Based Simulation mote ACP. Course for Advance Care Planning Palliative Care Knowledge and Attitudes of Facilitators (TH340A) Multidisciplinary Health Profession William Bond, MD MS, OSF HealthCare/University of Trainees (TH340B) Illinois COM, Jump Simulation, Peoria, IL. Linda Nathan Boucher, DPH MPA MS PA, Durham VA Med- Fehr, BSN RN CPHQ, OSF Healthcare System, Peoria, ical Center GRECC/Duke University, Durham, NC. IL. Amy Funk, PhD RN-BC, Illinois Wesleyan Univer- Jessica Sautter, PhD, University of the Sciences, Phila- sity, Bloomington, IL. Robert Sawicki, MD HMDC delphia, PA. Anita Franzione, DrPH, Rutgers Univer- FAAFP FAAHPM, OSF Health Care, Peoria, IL. Hanna sity, New Brunswick, NJ. Gonzalez, BS, University of Illinois College of Medi- Objectives cine, Peoria, IL. Jeremy McGarvey, MS, OSF Health- Describe the reported KNOWLEDGE of palliative care System, Peoria, IL. Jessica Svendsen, BA CCRC, care and end-of-life care of a multidisciplinary OSF Healthcare, Peoria, IL. health professions sample. Original Research Background. Advancecareplan- Describe the reported ATTITUDES towards palli- ning (ACP) facilitators require training and feedback to ative care and end-of-life care of a multidisci- acquire confidence to perform this valuable service. plinary health professions sample. Research Objective. To improve the knowledge and Original Research Background. A strong interpro- confidence of novice ACP facilitators. fessional palliative care workforce is needed to care Vol. 53 No. 2 February 2017 Schedule With Abstracts 335

for the growing older American population, in MN. Carolyn Lefkowits, MD MPH MS, University of particular. The Institute of Medicine (2014) criti- Colorado Denver, Denver, CO. cally noted the inadequately staffed palliative care Objectives workforce and recommended increasing training Describe the background evidence for communi- and exposure in primary palliative care for all health cation skills training (CST) in improving health professionals. Research Objectives. care providers’ skills. We wanted to examine multi- Describe the content of the CST we developed for ple health professions’ knowledge, attitudes, and in- gynecologic oncology providers. tentions towards palliative care. Describe the impact of the CST on the GO pro- Methods. During May-April 2016, we conducted an viders, as evaluated by pre- and post-intervention IRB-approved online survey of 360 students in their surveys. final years of training in pharmacy, medicine, nursing, Original Research Background. Good communica- physician assistant, occupational therapy, physical tion is crucial to good patient care, particularly in the therapy, and public health programs at five univer- setting of serious illnesses like cancer. Communication sities. We queried their knowledge and attitudes skills training (CST) has been shown to improve skill regarding palliative care and care delivered near the acquisition in providers of multiple specialties, but it end of life. has not been described in providers from gynecologic Results. Sufficient knowledge of palliative care was oncology (GO) or any surgical oncologic specialty. reported by 25% of the sample while sufficient Research Objectives. 1.To demonstrate feasibility knowledge of advance care planning was reported and acceptability of a communication skills training by 17%. Respondents (96%) thought it was impor- workshop for GO providers tant to discuss end-of-life issues in their training 2.To evaluate the impact of the training on perceived curricula; 92% believed their profession could play preparedness to address communication challenges an important role in patients’ end-of-life care. Man- and anticipated impact on clinical practice aging pain was reported as the best example of palli- Methods. We conducted a two-day CST workshop in the ative care by 93.6% over removing life sustaining VitalTalk model with 4 faculty members (2 gynecologic equipment (2.5%) and performing surgery to cure oncologists and 2 palliative care physicians) and 10 gyne- illness (2.5%). Designating a health care proxy was cologic oncology provider participants (5 fellows and 5 reported as the best example of advance care plan- advanced practice providers). Acceptability, perceived ning by 55.8%. We will discuss these and other find- impact on preparedness to address challenging commu- ings related to each professional subsets’ nication scenarios, and anticipated impact on practice perceptions of their didactic preparation in pallia- patterns were assessed by self-report pre- and immedi- tive care, knowledge of palliative care access/func- ately-post-workshop. We compared pre-workshop and tion, attitudes about death/dying, and intentions post-workshop prevalence of score of 4 or 5 on a 5-point to care for seriously ill patients in their future Likert scale for perceived preparedness to handle 14 chal- practice. lenging communication scenarios. Conclusion. There is interest in palliative care, Results. Participants showed statistically-significant including end-of-life care, and knowledge of its func- increase in perceived preparedness for 13 out of 14 tion among students from multiple health professions. Implications for Research, Policy, or Practice. challenging communication scenarios described in our pre-post questionnaire. Among those 13 topics, These findings can provide guidance for how we train magnitude of improvement in proportion rating pre- health professionals from multiple disciplines to care paredness 4 or 5 out of 5 ranged from 0.4 to 1 (all for the people they will serve in their future profes- p<0.05). All participants recommend the course to sional practice. others and all strongly agreed that this training should be required of all GO clinicians. Critical Conversations in Gynecologic Conclusion. Participants felt strongly that the work- Oncology: Communication Skills Training shop provided high quality education relevant to their for Fellows and Advanced Practice Providers practice. As a result of the workshop, participants re- in a Primarily Surgical Specialty (TH340C) ported statistically significantly increased perceived Lisa Podgurski, MD MS, University of Pittsburgh Med- preparedness to handle challenging communication ical Center, Pittsburgh, PA. Kerri Bevis, MD MSPH, scenarios. CST is feasible and has high perceived effec- University of Alabama at Birmingham, Birmingham, tiveness for clinicians in the primarily surgical onco- AL. Elise Carey, MD FAAHPM, Mayo Clinic, Rochester, logic specialty of gynecologic oncology. 336 Schedule With Abstracts Vol. 53 No. 2 February 2017

Implications for research, policy or practice. between advance directives and POLST regardless Communication skills training can be successfully of the years of training or number of completed applied in a surgical oncology setting. POLST forms. POLST: House Staff Knowledge and Attitudes (TH340D) Expanding Access to Community-Based Zankhana Mehta, MD, Geisinger Health System, Dan- Palliative Care: A Palliative Care in Home ville, PA. Kelly Downey, MD, Geisinger Medical Center, Health (PCHH) Model (TH341A) Danville, PA. Sharon Larson, PhD, Geisinger Health Marilyn Bookbinder, RN MJHS, New York, NY. Mary System, Danville, PA. Mellar Davis, MD FAAHPM Wagner, MEd RN MJHS, New York, NY. Kathleen FCCP, Geisinger Medical Center, Danville, PA. Dier, MSN RN MJHS, Home Care, Brooklyn, NY. Lor- ette Shea, MPS BSN RN, MJHS Institute For Innova- Objectives tion In Palliative Care, New York, NY. Russell Demonstrate need for POLST training for house Portenoy, MD, MJHS Hospice and Palliative Care, staff. New York, NY. Lenard Parisi, MA RN CPHQ FNAHQ Discuss differences between advance directives MJHS, New York, NY. and POLST. Objectives Background. Documenting patients’ preferences Describe an innovative model for delivery of com- for life-sustaining treatment across various sites of munity-based palliative care in home health care presents a challenge for the seriously ill. There (PCHH). is a paucity of data regarding trainees understanding Describe methods and results for evaluating feasi- of the Physicians Orders for Life Sustaining Treat- bility of the new PHHC. ment (POLST) tool application for advance care Original Research Background. In July 2016, The planning. Joint Commission issued its first certification for com- Methods. We utilized a survey tool to establish a base- munity-based palliative care in home health to MJHS line for house staff knowledge and attitudes related to Home Care, New York. Designed to expand access to POLST. We developed an on-line survey consisting of generalist-level palliative care, particularly in transi- 21 questions in the form of Likert scale, True or False, tional care, the Palliative Care in Home Health and multiple choice questions. Surveys were completed (PCHH) program has the potential to become a na- electronically by trainees using Survey Monkey. Out of tional model. 47 trainees who responded, 20 were from Internal med- Research Objectives. To describe the PCHH model icine, 9 were Med-Peds and 18 were from general sur- and evaluate its feasibility. gery, neurology, emergency, critical care, pulmonary Methods. The PCHH program identifies patients and critical care, nephrology, and cardiology. 22 of re- based on diagnosis and illness burden. The program spondents had two or fewer years of post-graduate includes comprehensive assessment by a home health training and 25 had more than two years of training. nurse within an interdisciplinary team (IDT); regular Results. 79% of respondents had reviewed and evaluation using the ESAS-r; front-loading of nurse completed POLST during their training. 67% felt visits; protocolized interventions for pain, dyspnea, comfortable discussing and completing POLST forms anxiety, and depression; assistance with advance care with patients. However 20% did not know which pa- planning; medication reconciliation and assistance in tients were appropriate for POLST discussions. 77% acquiring concrete services; hospice eligibility review identified that health care professionals must sign and education; and ongoing discussion with the pri- POLST form but 72% answered incorrectly or did mary physician. Implementation involved modifica- not know which sections to complete. 49% answered tion of the electronic medical record, training of incorrectly or did not know that POLST is not based both nurses and social workers, and establishment of on existing advance directive. 51% of respondents the IDT. preferred to call Palliative Medicine for questions Results. To date, 8 patients have been managed by related to POLST. 91% agreed to have additional the PCCH program; 8 were identified on hospital POLST training. discharge. All had advanced illness (CHF, cancer, or Conclusions. Our survey demonstrates a lack of COPD). Adherence to the protocols was 96%, understanding of POLST which needs to be including repeated visits within 48 hours. Care plan- improved by education before implementation. ning discussed at a weekly IDT meeting led to: hospice Many trainees are not clear on differences referrals (3), changes in management for pain (4), Vol. 53 No. 2 February 2017 Schedule With Abstracts 337

dyspnea (4), anxiety (4), depression (2) and clarifica- Results. For hospitalized patients, the presence of a tion of advance directives (8). One patient died dur- SID is associated with referral to PC (OR 2.6) and ing the care episode after emergency transfer to the death within 12 months (OR 3.3). Hospitalized pa- hospital. tients with a SID carry that diagnosis for an average Conclusion. PCHH appears to be a feasible model to of 16.4 months prior to death. However, 41.2% of expand access to generalist-level palliative care in the patients referred to inpatient PC do not have a SID. home care environment and may be particularly For ambulatory cancer patients, presence of a SID is important to improve transitional care between the associated with referral to PC (OR 2.7) and death hospital and home. within 12 months (OR 18.9). Ambulatory cancer pa- Implications for research, policy or practice. tients with a SID carry that diagnosis for an average Larger studies over a longer periods are needed to of 16.1 months. However, 42.6% of patients referred evaluate the clinical and economic outcomes of this to outpatient PC do not have a SID. model in varied populations. For primary care patients, presence of a SID is strongly associated with death within 12 months (OR 30). Pri- mary care patients with a SID carry that diagnosis for Screening Patients for Early Palliative Care: an average of 25.8 months. Can Serious Illness Diagnoses Identify Among patients with a SID, a minority has an advance directive (hospital¼24.5%, cancer cen- Patients Likely to Benefit from Palliative ¼ ¼ Care? (TH341B) ter 16.4%, primary care 31.2%). A smaller minor- ity has a Physician Orders for Life-Sustaining Kara Bischoff, MD, University of California San Fran- Treatment form (hospital¼4.7%, cancer cen- cisco, San Francisco, CA. Joanne Yim, PhD, University ter¼2.0%, primary care¼9.1%). of California San Francisco, San Francisco, CA. Teri Conclusion. Rose University of California San Francisco, San Fran- Serious illness diagnoses derived by cisco, CA. Christine Ritchie, MD FAAHPM, University expert consensus can identify many, but not all, pa- tients who are likely to benefit from PC. of California San Francisco, San Francisco, CA. Steven Implications for research, policy or practice. Pantilat, MD FAAHPM, University of California San Francisco, San Francisco, CA. Efforts are underway to design a robust screen to iden- tify patients in need of PC early. Objectives Understand how a list of serious illness diagnoses, derived through expert consensus for the purpose Palliative Care Office Hours: An Innovative of quality measurement, can be used to predict pa- Model for Care Delivery and Education tients’ eventual referral to palliative care and (TH341C) death. Anessa Foxwell, MSN ACHPN CRNP, Hospital of the Consider the strengths and limitations of this list University of Pennsylvania, Philadelphia, PA. Mary of serious illness diagnoses for the purposes of Moyer, BSN RN, Hospital of the University of Pennsyl- screening patients into early palliative care. vania, Philadelphia, PA. Nina O’Connor, MD, Univer- Original Research Background. Early PC is associ- sity of Pennsylvania, Philadelphia, PA. ated with better outcomes and lower costs. Proactive Objectives screening can identify patients in need of PC earlier List three patient populations for which palliative than usual referral mechanisms. An expert panel care office hours would be effective. developed a list of serious illness diagnoses (SID) - Describe implementation of palliative care office including metastatic cancer, end-stage heart failure hours. and advanced dementia - for the purposes of quality Describe the impact of palliative care office hours measurement. on palliative care consult volume, composition, Research Objectives. We examined whether these and outcomes. SID could be used to screen patients for early PC. Original Research Background. Many palliative Methods. We examined data from encounters at care programs are experiencing rapid growth, with de- University of California, San Francisco Medical Cen- mand for consults surpassing staffing. Innovative ter from 07/01/2012 to 06/30/2015 to determine models are needed to efficiently deliver palliative associations between SID and referral to PC or care and to equip non-palliative care providers to death. manage basic palliative care issues. 338 Schedule With Abstracts Vol. 53 No. 2 February 2017

Research Objectives. To describe a novel program Quantify degree to which patients may have math- of palliative care office hours for oncology advanced ematically inadequate opiate dosing based on practice providers, and to evaluate the impact of the home OME use. office hours program on palliative care consult vol- Compare adequate vs. inadequate dosing based ume and composition. on years of training. Methods. A palliative care nurse practitioner or pharma- Original Research Background. There are no previ- cist was available daily to the hematologic oncology ously published studies examining opioid doses advanced practice providers to answer questions about administered to opioid-tolerant cancer patients dur- pain, non-pain symptoms, and psychosocial distress. ing Emergency Department (ED) encounters. Data were collected on office hour utilization and pallia- Research Objectives. We performed a retrospec- tive care consults from the hematologic oncology services. tive review of ED management of pain in opioid- Results. Palliative care office hours were efficient tolerant cancer patients in our academic tertiary (mean duration of 16 minutes per day, range 5 to care cancer center over a 2-year period. The objec- 55) and well-utilized (mean of 11 patients discussed tive was to determine if opioid-tolerant cancer pa- per week, range 4 to 20). Pain, nausea, and anxiety tients presenting with acute pain exacerbations were the issues most frequently raised during office receive adequate initial doses of PRN opioids during hours. Of the 299 patients discussed during office ED encounters based on home Oral Morphine hours in the first six months, only 61 (20.4%) required Equivalents (OME) use. a full palliative care consult. After implementation of Methods. The percentage of patients that received an office hours, full palliative care consults were less likely adequate initial dose of PRN opioid (defined as $10% to be for pain (26.2% versus 56.3%, p ¼ 0.002) and of total 24-hour ambulatory OME) was evaluated. Lo- more likely to be for goals of care (11.4% versus gistic regression was used to establish the relationship 1.1%, p ¼ 0.007). Overall, palliative care consults between 24-hour ambulatory OME and initial ED from the hematologic oncology services decreased by OME to assess whether higher home usage was associ- 30% with no impact on hospice referrals. ated with higher likelihood of being undertreated. Conclusion. Office hours are an efficient model Results. Of 216 patients, 61.1% of patients received an when demand for palliative care consults exceeds adequate initial PRN dose of opioid in the ED. Of pa- capacity. tients taking <200 OME per day at home, 77.4% Implications for research, policy or practice. received an adequate initial dose; however, only 3.2% Office hours are likely to be effective for other patient of patients taking >400 OME per day at home received populations with frequent palliative care needs. Office an adequate dose. Patients with ambulatory 24-hour hours also serve an important educational function, OME >400 had 99% lower odds of receiving an enabling primary teams to manage basic palliative adequate initial dose of PRN opioid in the ED care issues so that palliative care specialists can focus compared to patients with ambulatory 24-hour OME on complex symptom management and goals of care. less than 100 (OR <0.01, CI 0.00-0.02, p <0.001). Conclusion. Patients with daily home use less than 200 OME generally received adequate initial PRN Evaluation of Emergency Department opioid doses during their ED visit. However, patients Management of Opioid-Tolerant Cancer with higher home opioid usage were at increased like- Patients with Acute Pain (TH341D) lihood of being undertreated. Implications for research, policy or practice. Pina Patel, MD, The Ohio State University Wexner Medical Center, Columbus, OH. Lauren Goodman, Further investigation regarding the impact of pain MD MSC, Ohio State University, Columbus, OH. Sheri management education for ED providers and avail- Knepel, MD, Zusman Hospice, New Albany, OH. ability of Palliative consultation services is vital for Charles Miller, MD, The Ohio State University Wexner the emergency care of cancer patients with pain. Medical Center, Columbus, OH. Asma Azimi, MD, Alta Bates Summit Hospital, Columbus, OH. Jillian Gustin, Extremis: An Insider’s Glimpse into the ICU MD, The Ohio State University Wexner Medical Cen- (TH342) ter, Columbus, OH. Amber Hartman, PharmD, The Jessica Zitter, MD MPH, Highland Hospital, Oakland, Ohio State University Wexner Medical Center, Colum- CA. bus, OH. Objectives Objectives Identify typical obstacles to breaking bad news in Recognize that opioid-tolerant cancer patients are the ICU environment, including communication at risk of being undertreated with opiate dosing challenges, medical uncertainty, and navigating during ED encounters. conflict. Vol. 53 No. 2 February 2017 Schedule With Abstracts 339

Recognize the importance of early, frequent, and Listen across difference. clear communication about prognosis in the ICU, Health care access, serving clients, and working including potential changes in medical decision within our community is incredibly important work. making. To best do this work, we need to know who we are, Join us for an exclusive screening of Extremis, a verite what we bring to the table, and what we don’t know. documentary exploring the harrowing decisions facing Join in for a lively conversation to uncover what we patients, families and physicians in urgent end-of-life don’t know, and how step 1 is asking the right ques- cases. We will explore the complex topics raised by the tions of ourselves and listening to others. Once you filmdincluding communication challenges, medical know who and how you are, you can reclaim respon- uncertainty, and navigating conflictdthat are major sibility for these behavior response patterns and leave components of the care of critically-ill patients. room for others to do the same. Before you know it, Directed by Emmy and Academy Award-nominated you are having better conversations and fuller rela- filmmaker Dan Krauss, Extremis follows Dr. Jessica Zit- tionships with those around you. I promisedit is ter and her team in the intensive care unit of a public that easy. hospital in Oakland, California. The extraordinary ac- Feel welcomed to a conversation about the cess granted in this 24-minute film offers a uniquely unknown. intimate look at the intersection of science, faith, Understand the difference between social justice and humanity. and diversity. The film provides an opportunity to evaluate and Review real life stories, share and reflect on our discuss the approach to patients at the end of life in own experiences. the ICU. It contains examples of both productive and Learn how to listen and leave some wiggle room in problematic communication, and raises critical ques- difficult conversation with others. tions about how healthcare providers can best support Learn a 3 part framework or model for taking re- their patients through these challenging times. sponsibility of how they show up. Extremis premiered at the Tribeca Film Festival in April 2016 and won the award for Best Documentary Short. It was also awarded first prize for Bay Area Short at the Book Club Discussion San Francisco International Film Festival and will screen at the Sheffield Doc/Fest and AFI DOCS Film Festival in June 2016. ‘‘When Breath Becomes Air’’ By Paul Netflix will premiere the film, its first original short Kalanithi (TH353) documentary, in September 2016, and will translate the work into 20 languages. 3e4pm Nurses Leading Change and Transforming Care (TH354) Inaugural Nessa Coyle Palliative Nursing Leadership Lecture Public Policy Forum: Advancing Palliative Betty Ferrell, PhD MA FAAN FPCN. Care in Alternative Payment Models: Objectives Surviving and Thriving Under MACRA (TH350) Describe the career of Nessa Coyle, PhD FAAN, a pioneer and leader in palliative care. Phillip E. Rodgers, MD FAAHPM; and Harold D. Apply the lessons from this career to future leader- Miller. ship needs to advance palliative care. The field of palliative care has revolved over the Diversity & Inclusion Forum: Conversations past 30 years with contributions by pioneers in that Matter: Creating a Culture of the field who have defined and implemented palli- Inclusivity and Candor (TH352) ative care. This presentation launches the Nessa Jessica Pettitt, MEd BA, Good Enough Now, Eureka, Coyle Lectureship honoring Dr. Coyle’s significant CA. contributions which have advanced compassionate Objectives care for patients and families around the world. Understand what to do with positive and negative Lessons from her career will be summarized and bias. applied to the future needs for leadership devel- Communicate across difference. opment. 340 Schedule With Abstracts Vol. 53 No. 2 February 2017

4:30e5:30 pm and elicit member feedback on the proposed curric- ular milestones. Concurrent Sessions

Palliative Care and Population Health Adding Your Voice: Vetting the Curricular Management: Key Steps on the Path to Milestones for HPM Physicians in Training Integration (TH361) (TH360) Jean Kutner, MD MSPH FAAHPM, University of Colo- Jillian Gustin, MD, The Ohio State University, Colum- rado School of Medicine, Aurora, CO. Christine bus, OH. Lindy H. Landzaat, DO FAAHPM, University Ritchie, MD FAAHPM, University of California San of Kansas Medical Center, Kansas City, KS. Michael D. Francisco, San Francisco, CA. Margaret Reidy, MD, Barnett, MD MS FAAP, University of Alabama at Bir- and Margaret E. Reidy, M.D, PLLC, Pittsburgh, PA. mingham, Birmingham, AL. Gary T. Buckholz, MD Jean Haynes, MBA RN, UCHealth, Aurora, CO. HMDC FAAHPM, University of California San Diego, Objectives San Diego, CA. Jennifer M. Hwang, MD MHS, The Describe the current status, and predicted future, Children’s Hospital of Philadelphia, Philadelphia, of population health in the setting of the Afford- PA. Stacie K. Levine, MD FAAHPM, University of Chi- able Care Act. cago, Chicago, IL. Laura J. Morrison, MD FAAHPM, Identify post-acute care strategies that effectively Yale-New Haven Hospital, New Haven, CT. Tomasz meet the needs of patients with serious advanced Okon, MD, Marshfield Clinic, Marshfield, WI. Steven illness. M. Radwany, MD FACP FAAHPM, Summa Health Sys- Describe approaches for enhancing care for peo- tem, Akron, OH. Holly Yang, MD HMDC FACP ple with complex care needs and measuring the FAAHPM, Scripps Health/University of California effectiveness of these approaches. San Diego, San Diego, CA. Population health management seeks to harness the Objectives efforts of health care delivery systems, public health Discuss the progress of the AAHPM HPM EPAs/ agencies, community-based organizations, and many Curricular Milestones Workgroup. other entities to improve health outcomes in the com- Review the latest working draft of HPM Curricular munities they serve. The Affordable Care Act served as Milestones. a catalyst to population health management by pro- Provide input through a structured vetting process moting the implementation of accountable care orga- on how your own experience as an HPM clinician nizations (ACOs) to incentivize providers to take and/or educator is reflected in the Curricular responsibility for population health outcomes. Pallia- Milestones. tive care improves value in ACOs and other integrated With ACGME’s move to the Next Accreditation Sys- care delivery networks by increasing high-quality care tem (NAS), 3 new tools were introduced for medical and decreasing costs for the sickest patients. Through training. These include: 1. Reporting Milestonesdes- a combination of presentations, discussion, and indi- sentially a report card that training programs submit vidual reflective work, session attendees will develop twice a year to ACGME to document each resident an action plan for enhancing integration of palliative or fellow’s progress; 2. Entrustable Professional Activ- care into population health initiatives in their local ities (EPAs)dkey activities of the job that as fellows’ settings. Session faculty will address the following gain competence can be ‘‘entrusted’’ to them to topics: perform without supervision; and 3. Curricular Mile- Population health overview: stonesdmore detailed elements of a training pro- What does population health management look gram that help offer structure and curricular like under the Affordable Care Act? guidance to educators. The AAHPM HPM Curricular Commercial payers, Medicare ACOs, Medicare Milestones/EPAs Workgroup completed the develop- Advantage and bundled payments: how do these ment and distribution of HPM EPAs. The workgroup populations differ and what are the implications is now focused on the development of HPM curric- for program design? ular milestones. The goal is to produce a curricular Why should palliative care be engaged with popu- milestone set that is helpful and practical for HPM lation health management? fellowship programs in defining and standardizing Post-acute care strategy: HPM curricula across training programs. At the Key components of an effective post-acute care 2017 Assembly the workgroup will educate on these strategy important concepts, provide an update on workgroup The role for palliative care in comprehensive post- progress, share a drafted set of curricular milestones, acute care strategies Vol. 53 No. 2 February 2017 Schedule With Abstracts 341

Complex care, panel management and measurement: terms of eligibility or documentation requirements? How do you respond to hospital pressure to admit pa- Innovative approaches for addressing the needs of patients with complex care needs tients to GIP who are actively dying but otherwise asymptomatic? Do hospices who own their own ‘‘hos- Palliative care’s role in facilitating panel man- pice houses’’ have a greater misuse of GIP? We will agement use multiple case examples of patients who do and Selecting relevant process and outcome measures do not qualify for GIP and CC. The documentation Effecting change: necessary to justify admission and examples of Identifying key partnerships adequate and inadequate documentation will be pro- Shaping the message vided and discussed. Attendees will come away from Time will be alloted for a structured exercise in which participants will create action plans, identifying key this session with a strong understanding of the criteria for GIP and Continuous Care and how to ensure accu- stakeholders in their environment and shaping a mes- rate documentation. sage relevant to their local situation. These action plans, with timelines, will be shared among partici- pants for feedback from session faculty and peers. Seizing the Opportunity: Overcoming Barriers to the Use of Transmucosal Is This Patient GIP Eligible? Improving Midazolam in Hospice Patients (TH363) Your Hospice’s Compliance and Sam Perna, DO, University of Alabama at Documentation for General Inpatient and Birmingham, Birmingham, AL. James Rhinewalt, Continuous Care (TH362) MD, University of Alabama at Birmingham, Martina Meier, MD, Providence TrinityCare Hospice, Birmingham, AL. Erin Currie, PhD RN, University of Los Angeles, CA. Eric Prommer, MD HMDC Alabama at Birmingham, Birmingham, AL. FAAHPM, Greater Los Angeles Healthcare, Los An- geles, CA. Shaida Talebreza, MD HMDC FAAHPM, Objectives University of Utah, Salt Lake City, UT. Describe the current use of transmucosal midazo- lam to treat seizures in non-hospitalized, adult Objectives and pediatric, hospice patients. Gain profound knowledge of CMS regulations and Identify barriers to the use of transmucosal qualification criteria for GIP level of care. midazolam for non-hospitalized patients in the Be able to document a patient’s eligibility for GIP US. or continuous care. Describe implications for practice related to the Be aware of the OIG’s report and recommenda- use of transmucosal midazolam for non-hospital- tions made to CMS regarding oversight of GIP ized, adult and pediatric, hospice patients. claims and know red flags that should trigger Background. Seizures in hospice patients are distress- concern over appropriateness of GIP admission. ing events for caregivers. Rectal diazepam is the only The Office of Inspector General’s 2016 report on Hos- abortive therapy approved by the United States FDA pice General Inpatient Care (GIP) indicated a high for seizures occurring out of hospital. However, transmu- rate of misuse of GIP services; the report states that cosal (buccal and intranasal) midazolam hydrochloride 31% of all GIP stays were billed inappropriately in is less expensive and likely more acceptable for patient 2012. Typically, there was insufficient evidence of un- comfort/modesty. This treatment has been studied, managed symptoms warranting GIP level of care. Inap- approved, and included in clinical guidelines in many propriate GIP billing occurred more commonly in other countries. The purpose of this presentation is to For-Profit-Hospices and for GIP care provided in discuss the current use of transmucosal midazolam to Skilled Nursing Facilities. The OIG recommends that treat out of hospital seizures and implications for prac- CMS increase its oversight of GIP claims and follow tice in outpatient hospice settings. up on inappropriate GIP stays. This session will improve the participant’s understanding of both the Methods. A review of the literature and clinical prac- conditions that make patients eligible for GIP, and tice guidelines were used to investigate barriers and adequate documentation of GIP eligibility. For explore the feasibility of transmucosal midazolam example, how bad does a patient’s shortness of breath use in US outpatient hospice settings. Communica- or pain need to be in order to justify GIP? When is tions with national and state agencies, as well as inter- wound care complex enough to warrant GIP admis- views with epileptologists, pharmacists, and a national sion? To what levels do treatments need to be changed hospice pharmaceutical supplier were completed to and titrated in order to justify GIP level of care? When investigate barriers and explore the feasibility of trans- should a patient be discharged from GIP? Is there a mucosal midazolam use. An electronic survey was uti- difference between GIP and continuous care (CC) in lized to explore transmucosal midazolam use among 342 Schedule With Abstracts Vol. 53 No. 2 February 2017

hospice physicians, nurses, and administrators in the curriculum and activities into their programs; (2) built state of Alabama. curriculum with equal interdisciplinary representation; Results. Transmucosal midazolam has been docu- (3) aligned the curriculum with the core competencies mented throughout the literature and has been re- established by the Interprofessional Education Collabo- ported by expert clinicians as an efficacious, safe, rative (values & ethics, roles & responsibilities, commu- and appropriate pharmaceutical intervention for the nication, and teamwork and team-based care) and (4) abortive treatment of seizures in non-hospitalized pa- leveled and involved learners from different disciplines tients. Barriers reported from the survey (N¼27) and academic levels. This session will address both op- included unfamiliarity with transmucosal route and portunities and challenges that were encountered, lack of provider orders. None of the respondents re- including: assessing institutional readiness, early plan- ported transmucosal midazolam use in the outpatient ning for IPE, creating and maintaining an interprofes- hospice setting. sional faculty team, educational strategies and Conclusion. Transmucosal midazolam hydrochloride resources for curricular development, logistical solu- is an effective, safe, cost-saving, and readily available tions, recruitment of appropriate learners from pallia- treatment for acute seizures in pediatric and adult hos- tive care disciplines, and evaluation methods and pice patients as an alternative to rectal diazepam. tools. Attendees will be linked to online resources Further research is necessary to understand barriers and organizations which provide materials and support to transmucosal midazolam in a larger, more represen- IPE initiatives. Presenters will share examples of suc- tative sample. Provider and patient education is cessful efforts through lecture, video and experiential needed to address a knowledge deficit on the use of activities. transmucosal midazolam in non-hospitalized hospice patients. There’s No Place Like Home: Creating a Successful Model for Community Based Pediatric Palliative and Hospice Care Interprofessional Education in Palliative (TH365) Care: A Report from the Trenches (TH364) Lily Gillmor, BSN RN CHPPN CHPN, Transitions Life- Barbara Head, PhD RN, CHPN FPCN, University of care, Raleigh, NC. Laura Patel, MD, Transitions Life- Louisville, Louisville, KY. Susan Breakwell, DNP Care, Raleigh, NC. Christopher Thompson, MD, APHN-BC, Marquette University, Milwaukee, WI. Dor- Transitions LifeCare, Raleigh, NC. Anne Donesky, PhD ANP-BC ACHPN, University of Objectives California San Francisco, San Francisco, CA. Identify both the need for and barriers to Objectives providing community based pediatric palliative Describe three strategies for overcoming common care. challenges when developing interprofessional Recognize the necessity of successful collaboration educational opportunities in palliative care. between inpatient and home based pediatric palli- Develop an evaluation plan for IPE. ative care programs. List educational strategies and resources available Identify the role Concurrent Care plays in pediat- for IPE. ric palliative and hospice care and the variability The recent IOM reports, Dying in America and Measuring between states. the Impact of Interprofessional Education on Collaborative Over the past 30 years there has been significant Practice and Patient Outcomes, challenge educational in- advancement in palliative care, however there con- stitutions to prepare clinicians who are competent in tinues to be a gap in pediatric services in both inpa- communication and collaboration across disciplines, tient and community based settings. There are particularly in palliative care. Such training mandates numerous reasons for this gap including funding interprofessional education (IPE) experiences, yet support, complexity of Concurrent Care, the defini- many efforts are thwarted by the multiple obstacles tion of and eligibility for palliative care services, and and lack of resources for developing and implementing the difficulty separating out palliative from hospice IPE. It is unusual for university-based palliative care IPE care.Whilethereisnotnearlythevolumeof curriculum to be developed from the ground up by research in pediatric palliative care as there is in multiple disciplines with equal representation. In this adult palliative care, the research that has been session, faculty from three universities with successful done strongly supports the use of pediatric palliative IPE programs will share lessons learned as they (1) suc- care, demonstrating its benefit in both the active cessfully developed and integrated interprofessional care of patients as well as during the bereavement Vol. 53 No. 2 February 2017 Schedule With Abstracts 343

process for parents whose child dies. Despite this suffering. However, there is currently a lack of a uni- strong evidence, pediatric palliative care continues versal standard for assessment and management of to be significantly underutilized. sexuality and intimacy within hospice and palliative This session will focus specifically on pediatric pallia- care. As crucial as intimate relationships are to our tive care in the home. We will present an interdisci- sense of well-being, providers may feel embarrassed plinary model of community-based palliative and or uncomfortable eliciting information about intimacy hospice care featuring four pathways of support. The or sexual wellness. Similarly, they may lack the re- rationale for each pathway will be discussed as well sources to adequately guide patients and families. as the successes and challenges, necessity of collabora- We will review assessment tools and techniques from tion with outside hospitals, and feasibility of replica- the literature that can be used to elicit important in- tion. Funding support will also be reviewed, formation about patient’s sexual and intimate rela- including a look at the Concurrent Care Waiver and tionships, as well as resources and responses that its implications on both a local and national level. providers in the interdisciplinary team can use to sup- The session will end with case examples of the care port the well-being of their patients’ intimate relation- provided in the different pathways, with time for a ships. Learners will have the opportunity to engage in brief question and answer session. practical communication to decrease fear or anxiety when addressing these topics. The Birds and Bees Do It, So Why Can’t We Talk About It? Intimacy and Sexuality in EOL Clinician at Work, EOL Caregiver at Serious Illness and at the End of Life HomedHELP Is on the Way! The Dual-Role (TH366) Caregiver Vulnerability Paradigm (TH367) Heather Shaw, GNP, Stanford University, Stanford, April Mazzarino-Willett, MSN ANP-BC ACHPN, Bays- CA. Joshua Fronk, DO, Stanford University School of tate Medical Center, Springfield, MA. Alice Leveston, Medicine, Palo Alto, CA. Felicia Hui, MD, Stanford MSW LICSW BCD, Baystate Medical Center, Spring- University, Palo Alto, CA. Karl Lorenz, MD MS field, MA. MSHS, Stanford University, Palo Alto, CA. Karla Objectives Schroeder, DNP MHA ANP-BC, Stanford Health Identify two pitfalls to the role of being both an Care, Palo Alto, CA. Ruth Kenemuth, MSW ASW, Stan- EOL Clinician while simultaneously being a fam- ford Health Care, Palo Alto, CA. Sharon Bober, PhD, ily caregiver for a terminally ill loved one [Dual- Dana-Farber Cancer Institute, Boston, MA. role Caregiver]. Objectives Describe two techniques to help the EOL Clini- Compare and contrast assessment tools that can cian adapt to their role, as a Dual-role Caregiver be used to assess sexual and intimate relationships when caring for a terminally ill loved one. in patients with serious illness. List two concurrent stressors faced by EOL Clini- Analyze ways in which assessing sexuality and inti- cians when they are asked to consult on cases of macy will improve the quality of care for patients nuclear or extended family members. and families. One of the most challenging events in the lives of fam- Identify barriers to and strategies for communica- ily caregivers is tending to a terminally ill loved one. tion about sexuality/intimacy with patients and But what happens when a family caregiver tending families. Apply and perform communication skills to a terminally ill loved one is also a practicing End that providers can use when assessing patient of Life (EOL) Clinician? What is an algorithm of sexuality and intimacy. care, specific burdens, coping vulnerabilities and Sexuality and intimacy are vital parts of the human grieving complexities of this Dual-role Caregiver experience and are ever present even with serious (both an EOL clinician while simultaneously being a illness or at the end of life. They are not synonymous family caregiver)? More importantly, how do we, the and have vastly different meanings for different pa- Interdisciplinary Team of EOL Clinicians, meet the tients. Furthermore, the perception and expectations specific needs of this population? of intimate and sexual relationships may change with Grounded theorist, Ireen M. Proot et al, 2003, notes disease progression, impacting any of the four corners family caregiving at end of life is a continuous balance of wellnessdphysical, social, psychological or spiritual. between care burden and capacity to cope, even in the Partnering with patients and families to address issues setting of courage and strength. Thankfully, EOL clini- affecting intimate relationships can promote well-be- cians are well versed in the specific burdens and ing in addition to decreasing grief and existential coping vulnerabilities of family caregivers caring for 344 Schedule With Abstracts Vol. 53 No. 2 February 2017

a terminally ill loved one and the core benefits of an vulnerable patients who have the greatest potential Interdisciplinary Team approach to care. to benefit from palliative care. Our palliative medicine A review of the literature yielded neither journal arti- team has partnered with our home health service to cles nor research studies with respect to this compli- identify those patients most at risk for increased cated clinician predicament. We therefore created a healthcare utilization and unmet healthcare needs. paradigm to explain and support the EOL Clinician By using a HIPAA-compliant video conferencing caring for either a nuclear or an extended terminally tool, we offer homebound patients an opportunity to ill family member utilizing Qualitative research speak with palliative medicine specialists working on method, Grounded Theory, the Stress-Vulnerability advance planning, goals of care discussions, and opti- Model, and our combined thirty personal experi- mizing symptoms in conjunction with their primary ences caring for both our nuclear and extended fam- providers. This not only provides patients an opportu- ily members. Through paradigm presentation, nity to maximize their quality time at home, but can discussion, and case examples, we will examine the also provide our home health partners the resources specific burdens, coping vulnerabilities, delayed grief they desperately need as they address end-of-life issues and an algorithm for caring for our own at end of and limit unwanted hospitalizations and utilization. life. This workshop will share the common issues home health professionals may face and how palliative med- Reaching Out to Those Who Can’t Reach Us: icine practitioners can improve patient care in the A Pilot Project Incorporating Palliative home setting. We also review ‘‘lessons learned’’ of over- Telemedicine in Home Health Practice coming challenges in communicating through tech- (TH368) nology and finding the opportunities for improved Matthew Peachey, MD, Vanderbilt Medical Center, care. Nashville, TN. Julia Triplett, MSN MBA NE-BC, Van- derbilt Home Care Services, Inc., Nashville, TN. Community Based Participatory Research: Mohana Karlekar, MD, Vanderbilt University, Nash- How to Use This Proven Method in ville, TN. Reducing Health Disparities in Palliative Objectives Care (TH369) Ronit Elk, PhD, University of South Carolina, Review the challenges and needs of homebound Columbia, SC. Marie Bakitas, DNSc NP-C FAAN, Uni- patients unable to reach appropriate palliative versity of Alabama at Birmingham, Birmingham, AL. care resources. Discuss the common needs home health practi- Objectives tioners have when dealing with serious illness Increase awareness and understanding of CBPR as and end-of-life situations. an important evidence-based tool to reduce health Share the development of a ‘‘smart-device-driven’’ disparities in Palliative Care. pilot program to connect homebound patients Discuss key principles and elements of CBPR. with palliative care resources. Explore which principles and tools participants One of the greatest challenges palliative medicine would use if they were to use CBPR. faces is reaching patients whose health has deterio- Community-Based Participatory Research (CBPR) is rated to a point they can no longer leave the home. a public health method that over the last 20 years Early palliative care can help patients receive the re- has demonstrated effectiveness in reducing health sources they need to honor their wishes to remain at care disparities across a variety of health care set- home, but a majority of palliative medicine is still pro- tings and illnesses. Using this method, researchers vided in an inpatient setting, often coming too late for partner with community members and together patients and families who wish to avoid further admis- design programs that meet the needs of the commu- sions. In rural communities, this issue is compounded nity or help to find solutions to problems that affect by the distance that must be traveled to reach appro- the community. Unlike most programs that are priate support. Many of these patients receive care at developed by experts, by using CBPR the commu- home through home health, but far too often pallia- nity members play a key and prominent role in tive care is not available through these agencies. As determining the elements of the program. A Com- technology has incorporated into medical practice it munity Advisory Board guides all aspects of the has opened the possibilities of communication be- study or program development, from beginning to tween patients and providers. We will discuss the insti- end. Because of this deep level of community partic- tution of a pilot project reaching out to those most ipation, involvement and input, the program or Vol. 53 No. 2 February 2017 Schedule With Abstracts 345

solution to the problem reflects the wishes of the Methods. Descriptive qualitative methods were community, and there is strong community owner- used. Data were drawn from and 30 individual ship of the program or solution once it has been im- pre-death interviews and 9post-deathinterviews plemented. This can result in increased community with the adolescents; all were part of a larger participation in palliative care programs, an grounded theory study on strategies to help ado- increased level of trust in the providers and health- lescents with a parent in hospice. The transcripts care organizations, and in teaching others in the were coded and analyzed using conventional con- community about the benefits of palliative care. tent analysis techniques by an interdisciplinary CBPR has only recently begun to be used in pallia- research team. tive care research or program development; there Results. Drawing from 25 families, 18 daughters and remains a large opportunity in palliative care to 12 sons described their interactions with hospice clini- use this evidence-based method to reduce demon- cians in a variety of ways. Four categories were identi- strated health care disparities in palliative care. fied: No Interactions (n ¼ 12), In-passing Interactions Although primarily used as a research method, the (n ¼6), Engaged, Interactions (n ¼6), and Formal In- principles of CBPR have strong relevance to clinical teractions (n ¼6). practice. For example, in designing a program to Conclusion. The majority of adolescents did not provide information to local community members describe a meaningful interaction with hospice clini- about palliative care. In this session participants cians. While some adolescents denied needs, many will gain an understanding of this exciting method teens did not even perceive that hospice clinicians and how it has been proven effective, and will un- were there to support them as well as their ill parent. derstand how they too can use it so that the voices Implications for research, policy or practice. In of the community they serve are heard and their order to bridge this gap, clinicians may need to ideas implemented. schedule visits outside the traditional work hours when teens are more likely to be at home. In addition, Paper Sessions functional decline in the ill parent may provide clini- cians an opportunity to connect with adolescents and offer support. Interactions Between Hospice Clinicians and Adolescents with a Parent Enrolled In Weighing Distress and Benefit: Hospice Care (TH370A) Understanding the Research Participation M. Mayo, ACHPN CHPN, Ursuline College, Cleve- Experiences of Bereaved Parents of Children land, OH. Denice Sheehan, PhD RN, Kent State Uni- with Medical Complexity (TH370B) versity, Kent, OH. Pam Stephenson, PhD RN AOCNS, Danielle Decourcey, MD MPH, Boston Children’s Hos- Kent State University, Kent, OH. Kim Heim, MSN RN pital, Boston, MA. Melanie Silverman, MPH, Boston APRN AOCNP, Cleveland Clinic/Akron General, Tall- Children’s Hospital, Boston, MA. Joanne Wolfe, MD madge, OH. Ghada Shahrour, MSN, Kent State Uni- MPH FAAHPM, Dana-Farber Cancer Institute, Boston, versity, Kent, OH. Claire Draucker, PhD RN FAAN, MA. Indiana University, Indianapolis, IN. Dana Hansen, Objectives PhD APRN ACHPN, Kent State University College of Understand the experiences of bereaved parent Nursing, Kent, OH. participating in survey based research. Objectives Describe factors associated with distress or benefit Identify four ways adolescents describe their inter- from the research participation experience of actions with hospice clinicians. bereaved parents of children with medical Cite one implication for practice. complexity. Original Research Background. Many adolescents Original Research Background. Improving end of in the United States experience not only the death life (EOL) care for children with medical complexity of a parent but also the stress of living in a house- (CMC) requires a better understanding of parent per- hold with a parent who is dying. Little research is spectives, yet tension exists around vulnerability of published from the teens’ perspective on their bereaved parent participation in research. Human needsandtheroleofthehospiceclinicianswith subject protection committees (HSPCs) must weigh the adolescents. the emotional impact of research participation with Research Objectives. To describe the ways in which potential benefits, however, studies assessing the risks adolescents and hospice clinicians interact during the and benefits of such participation for bereaved par- time a parent is near the end of life. ents are lacking. 346 Schedule With Abstracts Vol. 53 No. 2 February 2017

Research Objectives. To examine bereaved parent Original Research Background. When a parent is experiences during participation in a study of diagnosed with a life limiting illness, one of the communication around advance care planning mostdifficulttasksfacingtheparentsisinforming (ACP) and EOL care and to identify factors associ- their children. This study describes four ways in ated with distress or benefit from the research which parents disclose information about a parent’s experience. life limiting illness and death to their adolescent Methods. We surveyed 108 bereaved parents of CMC children. (65% response rate), who received care at Boston Research Objectives. To explicate ways in which par- Children’s Hospital from 2008-2015. The survey ents tell their adolescents about a parent’s life limiting focused on communication around prognosis, ACP, illness and death. and EOL care. At the end, parents were asked about Methods. Descriptive qualitative methods were their comfort, distress and benefit from survey used. Data were drawn from and 56 individual pre- completion. death and 15 post death interviews with hospice pa- Results. A majority of parents (78%) felt comfortable tients, spouses and their adolescent children; all completing the survey and reported benefit associated were part of a larger grounded theory study on stra- with participation (87%). Only 4% of parents re- tegies to help adolescents with a parent in hospice. ported that participation caused ‘‘a great deal’’ of The interviews were digitally recorded and tran- distress and of those reporting ‘‘a great deal of scribed verbatim. The transcripts were coded and distress,’’ 86% still found it beneficial (p¼0.05). analyzed using conventional content analysis Gender was associated with differences in perceived techniques. benefit with 24% of males vs 4% of females Results. Parents informed adolescents about a par- (p¼0.04) deriving ‘‘no benefit at all’’ from participa- ent’s life limiting illness and imminent death in tion. Parent age, gender, religiousness, spirituality or ways that were intended to ease the adolescents’ time since child’s death had no influence on distress. distress. The parents engaged in the process of Parents more often reported distress when they disclosure in one of four ways: measured telling; endorsed decisional regret about their child’s EOL skirted telling; matter-of-fact telling; inconsistent care (OR 3.21, p ¼ 0.015). telling. Conclusion. A majority of participating parents were Conclusion. The findings support a framework that able to respond to questions about their child’s EOL describes the processes of disclosure of a parent’s care without significant distress, and when present, illness, imminent death and death to their adolescent distress was often accompanied by a perception that children. Pre death findings about the ways the adoles- participation was beneficial. cents were informed were consistent with the post Implications for Research, Policy, or Practice. death findings. Parent perspectives are crucial to advance pediatric Implications for research, policy or practice. palliative care and HSPCs should be reassured that These results can be used to inform the development parents are willing participants and benefit from the of interventions in which health care professionals experience. assist families with disclosure pre and post death by tailoring strategies according to the family’s communi- cation style. Difficult Conversations: Telling Adolescents About a Parent’s Life Limiting Illness and The Benefits and Burdens of Cancer: A Death (TH370C) Prospective, Longitudinal Cohort Study of Denice Sheehan, PhD RN, Kent State University, Kent, Adolescents and Young Adults (TH370D) OH. M. Mayo, ACHPN CHPN, Ursuline College, Joelle Straehla, MD, Boston Children’s Hospital/ Cleveland, OH. Dana Hansen, PhD ACHPN, Kent Dana-Farber Cancer Cent, Boston, MA. Krysta Barton, State University, Kent, OH. Pam Stephenson, PhD PhD MPH, Seattle Children’s Research Institute, Seat- RN AOCNS, Kent State University, Kent, OH. tle, WA. Joyce Yi-Frazier, PhD, Seattle Children’s Objectives Research Institute, Seattle, WA. Scott Baker, MD MS, Describe four ways parents tell their adolescent Fred Hutchinson Cancer Research Center, Seattle, children that a parent has a life threatening WA. Kira Bona, MD MPH, Dana-Farber Cancer Insti- illness. tute, Boston, MA. Joanne Wolfe, MD MPH FAAHPM, Identify one implication for research. Dana-Farber Cancer Institute, Boston, MA. Abby Vol. 53 No. 2 February 2017 Schedule With Abstracts 347

Rosenberg, MD MS, Seattle Children’s Hospital, Seat- interventions to encourage additional benefit-finding tle, WA. and potentially improve outcomes. Objectives Become familiar with the unique perspectives Medication Changes on Discharge from of coping with cancer according to adolescents Acute Care to Hospice (TH371A) and young adults (AYAs). Jon Furuno, PhD, Oregon State University/Oregon Describe content of AYA patient-reported Health & Science University College of Pharmacy, benefits and burdens of cancer, including Portland, OR. Brie Noble, BS, Oregon State University physical distress, existential growth, and College of Pharmacy, Portland, OR. Seiko Izumi, PhD meaning-making. RN, Oregon Health & Science University, Portland, Original Research Background. Adolescents and OR. Kirsten Kadoyama, BA, Oregon State University Young Adults (AYAs) with cancer are at high risk for College of Pharmacy, Portland, OR. Mary Lynn poor health and psychosocial outcomes. Positive psy- McPherson, PharmD BCPS CPE, University of Mary- chological responses such as benefit-finding may land Baltimore, Baltimore, MD. Jennifer Tjia, MD buffer the negative impacts of cancer, but they are MSCE, University of Massachusetts Medical School, poorly understood in this population. Worcester, MA. Carey Candrian, PhD, University of Research Objectives. We aimed to prospectively Colorado School of Medicine, Aurora, CO. Erik describe the content and trajectory of benefit- and Fromme, MD MSCRFAAHPM, Oregon Health & Sci- burden-finding among AYAs in order to develop po- ence University, Portland, OR tential targets for future intervention. Objectives Methods. One-on-one, semi-structured interviews Describe the burden of medications prescribed on were conducted with English-speaking AYA patients discharge from acute care to hospice care. (aged 14-25 years) within 60 days of diagnosis of a Describe the trend in medication prescribing non-Central Nervous System malignancy requiring behavior over time for patients discharged from chemotherapy, 6-12, and 12-18 months later. Interviews acute care to hospice care. were coded using directed content analyses with a priori Describe the frequency of medication changes on schema defined by existing theoretical frameworks discharge to hospice care. including changed sense of self, relationships, philoso- Original Research Background. The transition phy of life, and physical well-being. We compared the from acute care to hospice often requires patients, content, raw counts, and ratios of benefit-to-burden caregivers, and providers to make difficult decisions by patient and by time-point. regarding continuation, discontinuation, and initia- Results. Seventeen participants (mean age 17.1 tion of medications. years, SD¼2.7) with sarcoma (n¼8), acute leukemia Research Objectives. We quantified the frequency (n¼6), and lymphoma (n¼3) completed 44 inter- and documentation of medication orders for patients views with >100 hours of transcript-data. Twelve discharged from acute care to hospice care. participated in interviews at all three time-points. Methods. This was a retrospective cohort study of Average benefit counts were higher than average adult ($18 years) patients discharged directly from burden counts at each time-point; 68% of interviews Oregon Health & Science University Hospital to had a benefit-to-burden ratio >1. Positive changed hospice between 1/1/2010 and 3/31/2016. Data senseofselfwasthemostcommonbenefitacross were collected from an electronic repository of med- all time-points (44% of all reported benefits); re- ical record data. In addition, we manually reviewed a ports of physical distress were the most common consecutive sample of 100 patient discharge sum- burden (32%). Longitudinal analyses suggested an maries to quantify the frequency and documenta- evolution of perceptions; over time, participants tion of medication changes. Medication changes tended to focus less on physical manifestations of were defined as 1) continuation of medications but cancer and more on personal strengths and life changes in dose, route, or frequency, 2) discontinu- purpose. ation of medications, or 3) newly started Conclusion. AYAs with cancer identify more benefits medications. than burdens throughout their cancer treatment and Results. Among 1,499 discharges to hospice, the demonstrate rapid maturation of perspectives. mean (standard deviation) number of medications Implications for research, policy or practice. patients were receiving was 7.2 (4.8) and this num- These findings not only inform communication prac- berincreasedby0.34mediations/yearoverthestudy tices with AYAs, but also suggest opportunities for period, P < 0.001. Review of 96 discharge summaries 348 Schedule With Abstracts Vol. 53 No. 2 February 2017

(4 were excluded because of missing data) identified before admission, hospice length of stay and live 1,466 medication decisions (mean¼15.3 decisions discharge status. The demographic characteristics of per discharge summary) of which 441 (30%) were hospice patients not electing DNR status were to continue medications without changes, 103 described. Multivariable logistic regression was then (7%) were to continue medications but with used to determine the association between DNR or- changes, 458 (31%) were to start new medications, ders and live discharge status adjusting for demo- and 464 (32%) were to discontinue existing medica- graphic and illness characteristics. tions. Among medications that were initiated or Results. We captured 17,824 individuals admitted to changed, morphine was the most frequent new hospice and completing advance directive forms. Of medication (7%) and aspirin was the most these, 2,862 (16.1%) did not elect DNR status. Individ- frequently discontinued medication (5%). Only uals not electing DNR status compared to those who 38% of medication changes had a documented did were significantly younger (mean age 72.1, SD rationale for the change. 17.0 vs. 79.6, SD 14.2), more likely to be male Conclusion. Medication changes are common on (49.7% vs. 42.3%), more likely to be African American discharge to hospice and frequently lack documenta- (15.0% vs. 5.8%), more likely to have cancer (50.6% tion of the rationale for these changes. vs. 33.8%), and less likely to have dementia or frailty Implications for research, policy or practice. (19.6% vs. 25.9%). While hospitals are under increasing pressure to After adjusting for all demographic and illness char- discharge patients before they die, more research is acteristics, individuals not electing DNR at admis- needed to better understand the effect of medication sion to hospice had double the odds (Odds Ratio changes and to ensure a smooth transition to hospice. 2.01, 95% CI 1.56-2.59) of live discharge from hos- pice. This is equivalent to an adjusted live discharge Characteristics of Patients Who Elect Full rate of 6.1% for those with DNR orders vs 11.2% for Resuscitation Status During Enrollment in those without. the Medicare Hospice Benefit in Two Large Conclusion. Lack of DNR orders on hospice admis- Nonprofit Hospices: A Retrospective Review sion is highly predictive of hospice live discharge. (TH371B) Implications for research, policy or practice. This Claire Ankuda, MPH MD, University of Michigan, Ann presents an opportunity to prospectively identify and Arbor, MI. Evan Fonger, MD, Wayne State University, support this high risk population. Detroit, MI. Thomas O’Neil, MD, University of Michi- gan, Ann Arbor, MI. Objectives Hospice Visit Intensity by Physicians and Describe the characteristics of individuals on hos- Nurse Practitioners on the General Inpatient pice without DNR orders in place. Level of Care (TH371C) Thomas Christian, PhD, Abt Associates, Cambridge, Identify the relevance of this work to a hospice director. MA. Joan Teno, MD MS, University of Washington, Se- attle, WA. Pedro Gozalo, PhD, Brown University Original Research Background. Some patients School of Public Health, Providence, RI. Michael electthehospicebenefitandyetstilldonotfeel Plotzke, PhD, Abt Associates, Cambridge, MA. comfortable signing do not resuscitate (DNR) orders. Objectives Research Objectives. We aim to assess the character- Describe the rate of physician or nurse practi- istics of this population and as well as the association tioner services during GIP service. of DNR orders with hospice live discharge rates. Describe episode characteristics associated with Methods. This was a retrospective cross-sectional the rate of physician or nurse practitioner services analysis of medical records from two of Michigan’s during GIP service. largest nonprofit hospices. The cohort was comprised Original Research Background. The Medicare Hos- of patients enrolled in hospice from 2009-2014. pice Benefit’s General Inpatient (GIP) level of care is Dependent variable was the absence of DNR orders intended to provide for pain and symptom manage- on admission. Other variables include demographics ment in an inpatient facility that could not be (race, sex, age), primary diagnosis, place of residence managed in the patient’s home. Vol. 53 No. 2 February 2017 Schedule With Abstracts 349

Research Objectives. Examine how beneficiaries Examine the results of analysis of 2014 Medi- utilize physician and nurse practitioner services while care data regarding discharge patterns of MA receiving GIP care. vs. FFS. Methods. Retrospective cohort analysis of Medicare Original Research Background. When enrollees in hospice beneficiaries utilizing GIP during Federal Fis- Medicare Advantage (MA) plans elect hospice, all cal Year 2014 (FY2014). Using 100% Medicare hospice covered services are reimbursed under Medicare fee- and Part B claims from FY2014 we examined physician for-service (FFS). This financial arrangement may and nurse practitioner service visit intensity during incentivize MA plans to refer persons earlier to GIP. hospice. Results. We found that among the 1.5 million GIP Research Objectives. Characterize hospice discharge days serviced in FY2014, the majority of days patterns among MA plan members vs. fee-for-service (52.4%) were not associated with any recorded physi- (FFS) Medicare beneficiaries and examine whether pat- cian or nurse practitioner services. Rates of the terns differed by the MA concentrationintheHospital absence of these services were particularly high Referral Region (HRR). among hospice GIP days provided in (Acute) Inpa- Methods. The patterns of live discharges (early dis- tient Facilities (69.1% of days missing physician/ charges in the first 7 days, late discharges post 210 nurse practitioner services), Long-Term Care Hospi- days, and burdensome transitions defined as hos- tals (84.3% missing services), and Skilled Nursing Fa- pice live discharge, hospital admission, then hos- cilities (85.3% missing services). Moreover, one in pice readmission) between FFS and MA enrollees five hospice episodes that have at least three days of were examined as well as hospice length of stay sequential GIP care did not have any physician or among decedents in FY2014. A multivariate random nurse practitioner services recorded from either the effects effect model examined whether MA vs. FFS hospice or Part B claims; this was true for more hospice patients had differential patterns of than half of such episodes beginning in long-term discharge. care hospitals or skilled nursing facilities. We found Results. In FY2014, there were 1,212,537 hospice that over two-thirds of all GIP days are serviced in hos- discharges with 335,243 MA patients having a higher pice inpatient units and that cancer was the most unadjusted live discharge rate (15.7%) compared to common primary hospice diagnosis at admission 877,294 FFS hospice discharges (15.4%), though the among GIP days. Conclusion. rate did not differ after controlling for patient char- GIP is an important component of the acteristics (AOR 1.01, 95% CI 0.99 e 1.02). MA hos- hospice benefit and these findings underscore a pice patients had lower rates of early live discharges recent Office of Inspector General report finding vari- (9.1% vs. 9.7% AOR 0.87, 95% CI 0.84-0.91) and ation in the utilization of GIP. Implications for research, policy or prac- burdensome transitions (5.0% vs. 7.7% AOR 0.61, tice. 95% CI 0.58-0.64) but did not differ in late live Further research and monitoring is needed to discharge (AOR 0.98, 95% CI 0.96-1.01). Among ensure that hospice beneficiaries are receiving decedent discharges, MA hospice patients were less adequate care regardless of their setting of care. likely to have a 3 day length of stay (AOR 0.95, 95% CI 0.94-0.96) or hospice stay exceeding 180 Discharge Patterns in Medicare Advantage days (AOR 0.97, 95% CI 0.96-0.99). The concentra- vs. Fee for Service Hospice Patients tion of MA patients within the HRR did not impact (TH371D) these results. Joan Teno, MD MS, University of Washington, Seattle, Conclusion. MA enrollees compared to those in FFS WA. Thomas Christian, PhD, Abt Associates, Cam- experience lower rates of early live discharges, early bridge, MA. Michael Plotzke, PhD, Abt Associates, decedent discharges, and burdensome transitions. Cambridge, MA. Pedro Gozalo, PhD, Brown University The concentration of MA hospice patients did not School of Public Health, Providence RI. impact these findings. Objectives Implications for research, policy or practice: MA pa- Understand the current policy regarding Medi- tients’ discharge patterns were slightly less concerning care Advantage and Hospice. than FFS hospice patients. 350 Schedule With Abstracts Vol. 53 No. 2 February 2017

Friday, February 24 decision making to family. Additionally, staff experi- ence moral distress when ECMO is continued as a 7e8am ‘‘bridge to nowhere’’ for patients who are not candi- dates for any other therapies. To close this session, Concurrent Sessions we will discuss the critical role of the palliative care team in offering support for the front line clinicians who care for ECMO patients. Walking Across the Bridge to Nowhere: The Role of Palliative Care in the Support of Patients on ECMO (FR400) Rachel Klinedinst, MSN CCRN CRNP, Hospital of the University of Pennsylvania, Philadelphia, PA. Nina Advance Care Planning Billing Codes: O’Connor, MD, Hospital of the University of Pennsyl- Benefits and Barriers for Palliative Care vania, Philadelphia, PA. Jill Farabelli, MSW LCSW, Teams (FR401) University of Pennsylvania, Philadelphia, PA. Phillip Rodgers, MD FAAHPM, University of Michi- Objectives gan, Ann Arbor, MI. Describe the clinical indications for veno-venous Objectives (VV) and veno-arterial (VA) ECMO, as well as Describe the recently established Continuing basic prognostication during ECMO support. Procedural Terminology (CPT) codes for List three common themes that emerge from the Advance Care Planning services (ACP) in the psychosocial struggles faced by families of ECMO context of changing fee-for-service Medicare patients. reimbursement. Explain three strategies for facilitating effective Summarize key benefits, barriers and consider- goals of care conversations with families of ations related to reporting advance care planning ECMO patients. services separately through the new CPT codes. Extracorporeal membrane oxygenation (ECMO) is an Develop a strategy for your providers and team to advanced form of mechanical circulatory support for maximize the value of ACP code reporting. patients with severe respiratory or cardiac failure. Pre- Starting in January 2016, the Centers for Medicare and viously used only in the pediatric population, ECMO Medicaid Services (CMS) began making separate pay- has evolved over the past two decades into an increas- ment for Advance Care Planning (ACP) services deliv- ingly widespread intervention for patients of all ages. ered in the Medicare program. This decision has been ECMO provides total cardio-pulmonary support for a widely regarded as a significant step forward to period of days to weeks, with the goal of transitioning improve care for Medicare beneficiaries, and sup- to either recovery or other advanced therapies such as ported by the vast majority of health professional soci- VAD or transplant. Its use carries a substantial risk of eties, patient organizations, and advocacy groups for serious complications, and a significant proportion older adults. of patients die after withdrawal of ECMO support. While this policy change is intended to encourage all Palliative care providers face unique challenges and op- health professionals to engage in advance care plan- portunities in the care of ECMO patients. Because ning with their patients, it is particularly important ECMO is a bridge therapy, families often experience to palliative care providers and teams, for whom momentous distress in the face of uncertain outcomes. ACP is a fundamental and very frequently delivered This session will highlight the key role of interdisci- service. However, as palliative care teams have begun plinary palliative care teams in providing intensive psy- to implement strategies for reporting ACP codes, chosocial and emotional support to families. We will several questions have arisen, including: What are discuss strategies for early palliative care involvement the specific requirements to report the codes? How at initiation of ECMO, presence throughout the pro- can the codes be reported along with other evaluation cess of eligibility determination for advanced therapies, and management (E/M) services? Can the codes be and support after the decision for continued medical used to capture ACP services delivered by the entire interventions or withdrawal of life support. This session interdisciplinary team (including those who are not will also offer strategies for facilitating effective goals of usually able to bill for E/M services)? How does reim- care conversations about ECMO. bursement through reported ACP codes compare with Decision-making related to ECMO often invokes that via other mechanisms (i.e. time-base E/M codes ethical dilemmas. Some patients are placed emer- and/or prolonged services codes)? gently on ECMO during prolonged cardiac arrests, de- This session will focus on the key issues, benefits and laying the dying process and shifting the burden of considerations for palliative care professionals and Vol. 53 No. 2 February 2017 Schedule With Abstracts 351

teams who are reporting ACP codes. We will review the impact both for direct patient care and by providing structure and purpose of the codes, the context of primary palliative care education in areas where pallia- their reimbursement within broader payment change tive care resources may be scarce. in the Medicare program, specifics of documentation A third type of electronic palliative care delivery con- and reporting requirements, comparative reimburse- sists of increased clinician-patient communication ment, and mechanisms for integration into existing through smartphone app technology. Such technol- electronic health record platforms. ogy is helpful for gathering patient-reported metrics, Participants will then be invited to share their own ex- but also for real-time intervention to improve patient periences with implementing ACP code reporting stra- care and reduce healthcare utilization. Similar models tegies and mechanisms. The presenter will respond, have been used in other disease states such as conges- and stimulate discussion about best practices, and tive heart failure, and hence there could be a similar overcoming barriers to success. benefit in palliative care. For each domain, we will review the relevant clinical literature, explore case studies, and discuss pilot data Novel Palliative Care Delivery Mechanisms from our institution’s experience with electronic deliv- in an Increasingly Electronic World (FR402) ery models. In doing so, our hope is that audience Bethany Rose Daubman, MD, Massachusetts General members will leave feeling empowered to consider Hospital, North Billerica, MA. Leah Rosenberg, MD, development of electronic palliative care pathways at Massachusetts General Hospital, Cambridge, MA. Mi- their home institutions. hir Kamdar, MD, Massachusetts General Hospital, Bos- ton, MA. Objectives Policy Opportunity: Putting Palliative Care Review the benefits and drawbacks of traditional on the Agendas of the New Administration vs. electronic palliative care delivery systems within and Congress (FR403) Marian Grant, DNP CRNP ACHPN, The Coalition to the constraints of our current medical system. Transform Advanced Care, Reisterstown, MD. Diane Discuss the need for unique electronic palliative care delivery systems within three major domains: Meier, MD FACP FAAHPM, Icahn School of Medicine at Mount Sinai, New York, NY. peer-to-peer coaching, subspecialist-to-generalist education, and patient-to-clinician communication. Objectives Explore three electronic palliative care delivery Discuss the likely healthcare priorities of the new systems to address each domain: electronic pallia- administration and how palliative care could tive care consultations, teleconferences, and contribute to those priorities. symptom management mobile phone apps. Describe the new Congress and the extent to As the demand for palliative care exceeds the available which palliative care could become more of a pri- supply of palliative care specialists, innovative delivery ority there. mechanisms are rapidly becoming a necessity. In this Discuss the latest evidence on existing efforts to presentation we will discuss a variety of mechanisms promote palliative and hospice care through new that utilize technology to meet the expanding pallia- demonstration, delivery, and payment models. tive care needs in our healthcare system. Although it’s hard to know what the results of the 2016 Given the limited number palliative care specialists, the election will be, one thing is clear: whoever becomes concept of primary palliative care is gaining traction. President will have a new administration including One delivery mechanism that could significantly new heads of agencies like Health and Human Ser- augment primary palliative care education is electronic vices (HHS), the Centers for Medicare and Medicaid consultations. In this modality a primary care provider Services (CMS), the National Institute of Health submits a clinical question to an expert palliative care (NIH), etc. At the same time, there could be changes clinician, who reviews the clinical scenario and provides in who gets elected/re-elected to Congress. In both written recommendations electronically. This model cases, there will be the opportunities to educate new not only provides increased access for patients who leaders and their staff on the benefits and need for may be unable to see a palliative care specialist due to palliative care for those with serious illness. geographical or staffing constraints, but also effects This presentation will provide an overview of the legis- change through the broader goal of augmenting the lative and regulatory opportunities for palliative care primary palliative care skills of referring providers. for 2017 going forward. Attendees will get perspective For patients in countries where palliative care educa- on the new administration’s healthcare priorities tion is limited, utilizing technology for teleconferences along with suggestions on how palliative care could is crucial. These modalities can have far-reaching be positioned to help deliver those priorities. In 352 Schedule With Abstracts Vol. 53 No. 2 February 2017

addition, the new Congress will be analyzed and op- benefit from Palliative Care intervention? In this con- portunities for current key palliative care legislation, current session, members of the Palliative Care Team e.g. the Palliative Care and Hospice Education and will present the development and integration/embed- Training Act (PCHETA), will be reviewed. ding of Palliative Care in a high risk NICU, with plans The presentation will then include an update on the for long term follow up and identification of neonatal continuing work on new delivery and payment models palliative research endeavors. at CMS and any potential opportunities for palliative care there. Results from the first wave of CMS demon- ‘‘Be Prepared’’dClinical Applications and stration models will begin to be available later in 2016 Practical Guidance in Developing Culturally and so these will be reviewed as well. New and alter- Appropriate Advance Care Planning Tools nate payment systems coming out of the Medicare for American Indian and Alaska Native and CHIP Access Reauthorization Act (MACRA) will People (FR405) be also discussed since these will impact how future Christopher Piromalli, DO MPH, Alaska Native Tribal healthcare quality will be measured and paid for. Health Consortium, Anchorage, AK. Lisa Marr, MD, Participants will gain a better understanding of what the University of New Mexico, Albuquerque, NM. Rona federal policy priorities regarding palliative care are and Johnson, BSN RN OCN, Alaska Native Medical Center, also how they and their professional associations and co- Anchorage, AK. Stacy Kelley, MPH, Alaska Native alitions can participate in making them realities. Tribal Health Consortium, Anchorage, AK. Objectives When Fragility Translates to Empowerment: Discuss the concepts of cultural humility and its Integrating/Embedding Palliative Care in applications in advance care planning with Amer- the Neonatal Intensive Care Unit (FR404) ican Indian and Alaska Native People. Pamela Rowland, MSN CRNP, Children’s of Alabama, Describe the use of innovative clinical tools to Birmingham, AL. Lynn Vaughn, MSN RN, Children’s educate American Indian and Alaska Native pa- of Alabama, Birmingham, AL. Samuel Perna, DO, tients and families on advance care planning. Children’s of Alabama, University of Alabama at Bir- These tools include the use of advance care plan- mingham, Birmingham, AL. ning conversation maps, group visits and conver- Objectives sation guides. Describe integration/embedding process of Palli- Develop a framework to educate and equip health ative Care in the Neonatal Intensive Care Unit. care providers with advance care planning tools Utilize triggers based on disease/prognosis that and resources for culturally diverse and under- direct consult classification. served populations in urban and rural regions. Describe the use of an electronic program to Alaska Native and American Indian People (AN/AI notify Palliative Team of patient return for outpa- people) have diverse and rich cultural perspectives on tient visits and/or readmissions. advance care planning. There is very limited informa- A family preparing for the birth of a baby often ponders a tion and studies on advance care planning with AN/ new beginning; there are thoughts of hope, wonder, and AI people and the approaches on how to engage in dreams of possibilities. When plans for a healthy these conversations. The Alaska Native Tribal Health newborn are disrupted by critical illness, a considerable Consortium Palliative Care Program has developed amount of emotional and psychological burden is innovative clinical tools for advance care planning placed on parents and families in a short time frame. that integrate concepts of cultural humility to respect They are forced to reconcile their previous joyous plans the diverse traditions and cultures of AN/AI people. to their new reality; their baby’s future is now uncertain. By incorporating the traditions of storytelling and pic- There has been much advancement for treatments and tures, the concepts of advance care planning are technology in neonatal intensive care over the past explored through the innovative use of conversation several years. Parents, most who have no medical back- maps, group visits and conversation guides. With the ground, are now faced with the daunting task of navi- integration of motivational interviewing techniques, gating and trying to understand this strange new world these tools for advance care planning help to provide of words that are difficult to pronounce, life-saving ma- a culturally sensitive way to engage in these important chinery, medications, and procedures. If there is ever a conversations with patients and families of diverse cul- case for Palliative Care consult this would be that case. tural backgrounds. In addition, the Alaska Native Tribal Often, consults are missed due to clinician misunder- Health Consortium Palliative Care Program has helped standings, rotation, and time constraints. to integrate these advance care planning tools How can Palliative Care clinicians partner with NICU throughout the Alaska Tribal Health System in both ru- teams to identify patients and families who would ral and urban settings. Through these efforts, tools and Vol. 53 No. 2 February 2017 Schedule With Abstracts 353

resources have been provided to educate and equip To highlight implications of cutting edge health care providers and ancillary staff to have advance research of clinical value to American Academy care planning conversations in a variety of settings. of Hospice and Palliative Medicine members. PC-FACS (Fast Article Critical Summaries for Clinicians 8:15e10 am in Palliative Care), the highest rated member benefit of the American Academy of Hospice and Palliative Med- icine, offers busy clinicians an efficient way to stay on top Plenary Session of pertinent literature in a field that is growing exponen- tially. Now in its twelfth year, PC-FACS, published in the Redesigning the End-of-Life Experience Journal of Pain and Symptom Management and delivered (103) in a convenient format to the e-mail box of Academy members, provides topical summaries of just published Paul Bennett, CCO, IDEO, New York, NY. B.J. Miller, research from more than 100 journals that are not specif- MD, Zen Hospice Project, University of San Francisco, ically dedicated to hospice and palliative medicine and San Francisco, CA. might not otherwise come to the attention of our reader- Objectives ship. Editorial Board members, peer experts selected Educate the audience about the methods and ap- from Academy membership through a competitive pro- plications of Design Thinking in the Palliative cess, author succinct, thought provoking commentaries Care and Patient journey. that have practical implications for practice and for the Engage the audience in a collaborative dialogue field as a whole. Published reviews and commentaries about new solutions in the Palliative Care span the gamut from Basic Science through Bioethics, Industries. Humanities, and Spirituality; Geriatrics and Care Transi- Facilitate a conversation about ways for individ- tions; Hospice, Hospice and Palliative Medicine Inter- uals and organizations to engage in Design face, and Regulatory Issues; Pediatrics; Psychosocial; to Thinking. Symptom Assessment and Management. This past year, Using the format of a moderated conversation, Dr. we have piloted a new process for retrieving literature Miller and Mr. Bennett will cover 2 topic areas: that has yielded articles from an expanded repertoire 1. A general introduction to the practices and out- of journals and have broadened our editorial board to comes of Design Thinking. IDEO, where Mr. Ben- a greater number of disciplines. In this session, Editor- nett is the CCO, is the world leader in the in-Chief Donna S. Zhukovsky and Associate Editor-in- application of Design Thinking; showcasing ex- Chief Mellar Davis will take you on a lightning rod tour amples through multiple industries will hopefully of some of the most impactful literature reviewed the enlighten the audience. past year, connecting each paper to a case scenario to 2. Dr. Miller will talk about his own experiences in highlight its clinical relevance. Session participants will the world of Palliative Care and highlight where have an opportunity to contribute their own perspectives he feels there are opportunities for the world of of the literature for an enriched discussion of the clinical Design Thinking to intersect with this critical implications of this research. conversation. By facilitating a conversation between the audience and the speakers, we hope to have an enlightened dis- cussion to include everyone’s ideas and we will create It’s Not Alzheimers...Now What Do We Do? together a framework of tangible possibilities. A Discussion on the Course and Prognosis of Non-Alzheimer’s Dementias (FR411) Priya Pinto, MBBS, Montefiore Medical Center, Bronx, 10:45e11:45 am NY. Allison Stark, MD MBA, Montefiore Medical Cen- ter, Bronx, NY. Mirnova Ceide, MD, Montefiore Medi- Concurrent Sessions cal Center, Bronx, NY. Objectives PC-FACS: Year in Review (FR410) Identify and recognize differences in dementias other than Alzheimer’s. Donna Zhukovsky, MD FACP FAAHPM, MD Anderson Prognosticate and treat symptoms of dementias Cancer Center, Houston, TX. Mellar P. Davis, MD other than Alzheimer’s. FCCP FAAHPM, Geisinger Health System, Danville, PA. Dementia is not a specific disease. It’s an overall term Objectives that describes a wide range of symptoms associated To update session participants on PC-FACS pro- with a decline in memory or other thinking skills se- cesses and ‘‘Vital Statistics.’’ vere enough to reduce a person’s ability to perform 354 Schedule With Abstracts Vol. 53 No. 2 February 2017

everyday activities. Alzheimer’s accounts for 60 to 80 psychological, and social causes of these concerns. percent of cases. There are well over 100 causes of de- The National Quality Forum (NQF) preferred prac- mentia, but the big four that make up 94 to 98 percent tices guidelines for palliative and hospice care note, are Alzheimer’s disease, Lewy Body Dementia (LBD), ‘‘a social assessment plan should address sexuality/in- Frontotemporal dementia (FTD), and Vascular timacy.’’ Presently, palliative care providers do not Dementia. routinely address intimacy and sexual symptom con- No treatment specifically for LBD, FTD or Parkinsons cerns, leading to a dissonance between guideline rec- dementia exists. However, many of the newer medica- ommendations and practice. Additionally intimacy tions are beginning to show some impact on the and sexual symptom concerns may be underreported behavioral and motor aspects of these processes. and undertreated. Attendees of this session will leave Symptomatic treatments are available with medica- with an enhanced understanding of the literature tions developed for other disorders, such as psychiat- regarding intimacy and sexual symptoms in the pallia- ric medications for behavioral problems or mood tive care patient population. Attendees will also be disorders. However, even among symptomatic treat- able to perform a brief screening with their patients ments each diagnosis has a different risk and benefit to identify intimacy and sexual symptom concerns. ratio. There are no treatments for language problems. Furthermore, a review of sexual symptom pathophysi- The identification of non-Alzheimer’s dementias ology and intimacy will be provided, as well as a case impact the advance care planning process. Some, series to help attendees apply newly gained knowledge such as LBD and FTD, progress much faster and on screening, communication, and treatment to pa- care needs change more rapidly. Traditional hospice tient scenarios. admission criteria do not always account for some of the differences in prognostication and progression. Hospices as Providers of Community-Based A multi-disciplinary approach that includes physical Palliative Care: Exploring the Ins and Outs therapy and behavioral therapy could be beneficial (FR413) to patients and their families. As dementia progresses Jeanne Twohig, ACHP-SW ACHPN ACNS AGSF ANP patients require more oversight and families require AOCN AOCNP C, Center to Advance Palliative Care, more guidance and assistance. There is room for edu- New York, NY. Martha Twaddle, MD HMDC FACP cation and training of primary care providers, geriatri- FAAHPM, JourneyCare, Glenview, IL. Turner West, cians and palliative care doctors to identify and better MPH MTS, Hospice of the Bluegrass, Lexington, KY. prognosticate so we can achieve better outcomes for Richelle Nugent Hooper, MSN MBA FNP-BC these patients and families. ACHPN, Four Seasons, Flat Rock, NC. At the end of this session, through a series of case Objectives studies, providers will be better equipped to identify Describe why and how hospice organizations pro- and manage the complex behavioral and psycho-social vide natural administrative homes for providing aspects involved in caring for these patients. quality, cost-effective community-based palliative care services. Why is No One Talking About This? Identify two viable administrative structures that Addressing Intimacy and Sexual Concerns in hospice organizations use to differentiate the de- Patients with Serious Illness (FR412) livery of hospice services from community-based Renee Holder, PharmD BCPS CPE, MedStar Washing- palliative care services offered by hospice ton Hospital Center, Washington, DC. Anne Kelemen, organizations. ACHP-SW LICSW, MedStar Washington Hospital Cen- Describe how a hospice organization offering ter, Washington, DC. Farshid Sadeghi, MD, Arizona community-based palliative care services ad- Urology Specialists, Scottsdale, AZ. dresses the program’s operational features. Objectives Hospice organizations across the country are expand- Describe the existing evidence base on intimacy ing their services to offer palliative care programs as and sexual symptom assessment and treatment new business lines distinct from their hospice services. in the palliative care population. What essential aspects of planning and service delivery Perform an intimacy and sexual symptom should hospices consider as they launch community- screening and assessment. based palliative care programs? This session will Identify medical, psychological, and social issues feature representatives from three hospices who have leading to intimacy and sexual symptom concerns successfully designed and are operating community- in patients with serious illness. based palliative care programs: JourneyCare, a hospice Intimacy and sexual symptoms are a common concern in Illinois that offers home-based palliative care; Four in patients with advanced illness. There are medical, Seasons, a large hospice in western North Carolina Vol. 53 No. 2 February 2017 Schedule With Abstracts 355

with divisions offering home-based, office-based, and Weigh pros and cons and decide on providing Ani- inpatient palliative care programs; and Hospice of mal Assisted Visits and/or Animal Assisted Therapy. the Bluegrass, a hospice serving 32 counties in central, Obtain budget, support, and resources from southeast, and northern Kentucky that provides administration, volunteer services, quality/risk, consultative palliative care services to several hospitals. infection control, employee health and other Borrowing from the format of a town hall meeting, the related departments. three panelists will respond to questions from a Write and approve policies. moderator and session participants to describe their Create referral process; educate and disseminate organizations’ models. Attendees will learn the prac- to appropriate staff. tical ins and outs of administrative structures, staffing Obtain or identify Volunteer Coordinator(s) to patterns, service differentiation, patient identification recruit, interview, orient, assign and supervise and transition, and reimbursement strategies. Guided pet therapy volunteers including assurance of by the structured questions of the moderator, along pet therapy specific compliance issues. with the interactive dynamics of the town hall format, Become informed and clear on the differences session participants will explore with these leaders the between therapy and service animals. benefits, opportunities, and challenges their hospices In lieu of creating an internal agency program, alter- experience while offering community-based palliative native community options will be discussed. care as part of a hospice organization. Finally, the Participants will leave the session with the tools neces- moderator will summarize take-home messages from sary to build a successful pet therapy program. the discussion for the audience. Poetry for Patients: Learning to Read Poetry with Your Colleagues, Patients and Families: Integration of Fur, Paws, Whiskers and A Collaborative Workshop with the Poetry Hooves into your Agency-Enhancing Foundation (FR415) Patients’ Lives through Pet Therapy Nora Segar, MD, Northwestern University, Chicago, (FR414) IL. Joshua Hauser, MD, Northwestern and Jesse Brown Ann Roseman, MS CCLS, Hospice of the Valley, VA, Chicago, IL. Katherine Litwin, MLIS, Poetry Foun- Phoenix, AZ. dation, Chicago, IL. Whitney You, MD MPH, North- Objectives western University, Chicago, IL. Describe the benefits of and process to develop a Objectives pet therapy program. Describe the ‘Poetry for Patients’ Project at Compare and contrast Animal Assisted Activity Northwestern: Audience will be able to explain versus Animal Assisted Therapy and therapy the Poetry for Patients Project as it has been im- versus service animals. plemented at our institution. Pet therapy is a positive opportunity to diversify the Engage in close reading of key selected poems: psychosocial programs that hospice and palliative Learner will demonstrate close reading of a care agencies offer. There is wide agreement on the poem in one of three main categories: City, Na- benefits of pet therapy, including but not limited to: ture, or Health and Illness as selected and guided positive sensory stimulation by staff at the Poetry Foundation. Learner will be distraction from pain, distress and agitation able to discuss application of this exercise to their lightened mood work with patients. facilitation of communication and movement Develop strategies for how to read and analyze lowered blood pressure poems with patients and families: Learner will .and more be able to explain rationale for reading poetry Patients, families and staff talk about pet therapy natio- with patients and identify how they might apply nally.from the research findings, to firsthand accounts, concepts presented in the workshop in their to sharing amazing stories posted on social media. own patient care environment. This session will discuss how to offer pet therapy as an Background. While there is growing evidence that additional integrative therapy for hospice/palliative close reading of literature and reflective writing can care clients. Participants will learn how to create and improve providers’ appreciation of the patient experi- maintain a pet therapy program. ence, foster physician development and combat People assume the first step to pet therapy is acquiring burnout, there has been less work on the experience the pets. As important as this is, the many other inter- of reading literature with patients facing serious or mediary steps such as the following will be elaborated life-threatening illness. Longer form reading may be upon in the session: unsuitable for some portions of the palliative care 356 Schedule With Abstracts Vol. 53 No. 2 February 2017

population, given high burden of fatigue and possible Background. Since ancient times, marijuana has contribution of delirium. Time pressure may also pre- been used medicinally. It became illegal in the United clude discussion by a practitioner working in a busy States in the late 1930s with the federal passage of the clinical context. In contrast, we feel the condensed Marihuana Tax Act of 1937, was removed from the US medium of poetry presents a natural opportunity to Dispensatory and stripped of therapeutic legitimacy in engage patients with the medical humanities, helping 1942, and later was made a Schedule I drug by the them to articulate difficult or joyful experiences, and/ Controlled Substance Act (CSA) in the 1970s. Begin- or serving as necessary diversion when facing serious ning with California in 1996, many states from around illness. the country have begun to decriminalize medical Project description. Poetry for Patientsda project marijuana possession, and the US Department of Jus- developed through collaboration between North- tice announced that medical marijuana users who had western Memorial Hospital and the Poetry Foundation complied with state laws would not be prosecuted. An in Chicago, an independent literary organization increasing number of states allow medical marijuana committed to a vigorous presence for poetry in our for pediatric patients, as well. culturedhas developed three short collections of Discussion. There is a growing body of literature poems, and an accompanying discussion guide for which shows benefits for palliative care patients use specifically with patients and families. with the use of medical marijuana. This session will Objectives. In this workshop, we will describe our provide a review of the current evidence regarding experience of reading poems with patients and fam- medical marijuana with a focus on its use in pediat- ilies, engage in close reading of selected poems, and ric palliative care (PPC). Presenters will discuss identify an approach to reading poems with patients eligible patients (who), forms of medical marijuana in a variety of clinical settings. available for pediatric patients (what), an overview Methodology. In addition to describing our experi- and comparison of state regulations and hospital pol- ence, we will use interactive, mixed method didactics icies (where), a discussion of appropriate use and to engage participants. We will provide selected poems timing of use (when), best evidence regarding to participants and use a portion of the workshop space drug/drug interactions and the risks/benefits (why) for guided close reading. We will also provide partici- and instructions for parents on obtaining and pants with discussion guides to use with patients at their administering medical marijuana to their minor own institutions and copies of the poetry collections. child (how). Cases from 3 children’s hospitals Outcomes. Participants will leave the workshop with located in states where medical marijuana has been an appreciation for the therapeutic power of reading legalized from different regions of the United States poetry and gain the skills and knowledge necessary (East coast, Midwest, and Southwest) will be used to to read poetry with their own patients. illustrate the above. Conclusion. As an increasing number of states The Who, What, Where, When, Why and legalize medical marijuana for pediatric patients, it is How of Medical Marijuana in Pediatric important that PPC providers understand its use, Palliative Care (FR416) including the risks and benefits, so we are able to Billie Winegard, MD MPH, University of Illinois at Pe- guide and counsel families appropriately. oria, Peoria, IL. Elissa Miller, MD, Nemours/AI Du- Pont Hospital for Children, Wilmington, DE. Tressia The Professional Working GroupdHow to Shaw, MD, Phoenix Children’s Hospital, Phoenix, Create and Use a Process Group to Build AZ. Matthew Troester, DO, Barrow Neurological Insti- Community, Prevent Burnout, and Make tute at Phoenix Children’s Hospital, Phoenix, AZ. Work-Life Sustainable (FR417) Objectives Bonnie Chen, MD, Kaiser Permanente, Oakland, CA. Describe the pharmacology of medical marijuana Juliet Jacobsen, MD, Massachusetts General Hospital, and the forms available for pediatric patients, Boston, MA. Joshua Jones, MD MA, University of including a discussion of key drug/drug interactions. Pennsylvania Health System, Philadelphia, PA. Warren Describe state laws regarding the use of medical Lewin, MD, The Mount Sinai Hospital, New York City, marijuana for pediatric patients and discuss hos- NY. Jane DeLima Thomas, MD FAAHPM, Dana-Farber pital policy differences at children’s hospitals Cancer Institute, Boston, MA. Erica Tuggey, MS ANP- from different regions of the country. BC, Mount Sinai Medical Center, New York, NY. Identify the symptoms and diseases that a pediat- Objectives ric palliative care patient may benefit from medi- Recognize the domains of burnout and describe a cal marijuana use and discussed most recent model that predicts burnout using the gold stan- evidence to support its use. dard Maslach Burnout Inventory scale. Vol. 53 No. 2 February 2017 Schedule With Abstracts 357

Understand how a Balint group could be adapted Examine the role of the 30-day surgical mortality to the palliative care fellowship training setting to metric and potential conflict with patient goals. promote sustainability and prevent burnout. Critique the role of DNR status and self-fulfilling Discuss models for group support and peer mentoring prophecies. that can be used beyond fellowship training to (1) Quality Metrics have been applied in many different help participants identify work-related issues leading fields and are exponentially growing in medicine to burnout, (2) provide a support base to strategize and Palliative Medicine in particular. Although the ways to prevent burnout and increase engagement intention is admirable in the desire to quantify and and sustainability. measure good patient care, sometimes these metrics Burnout is a psychological syndrome occurring in have unintended consequences. Several areas of response to chronic interpersonal stressors affecting concern to be discussed in this session: up to 50% of the clinician workforce, and 62% of the 30-day mortality rule and surgery.Surgeons are gradedon palliative care workforce. Left unattended, burnout their 30-day mortality rates. Patients and families may not leads to job dissatisfaction, workplace turnover, and want to wait 30 days to withdraw life-sustaining treatment, increased clinician error. In order to prevent burnout, when they perceive the burden of that treatment is too palliative care fellowship must include training related great. Surgeons are sometimes unwilling to respect family to self-care and resilience. Based on our fellowship expe- wishes, given the consequences to their careers. As a cor- rience, we present a resiliency-building model for fellow- ollary, surgeons may be unwilling to operate on patients ship training and beyond that aims to prevent burnout, who may benefit, due to the risk of mortality. foster community, and make work-life sustainable. DNR and self-fulfilling prophecies. Although DNR is In this session, we will discuss the domains of burnout designed to not attempt resuscitation once the heart and describe a model that predicts risk of burnout us- stops, it is often applied as ‘‘do not treat.’’ Neurology ing the Maslach Burnout Inventory scale. We will then and trauma have specifically documented higher mor- outline palliative care fellowship core competencies tality rates and worse patient outcomes related to the related to burnout and resilience and explore how patient having a DNR order. Although the goal is to these competencies can be translated into a year- respect the patient’s and family’s wishes regarding long curriculum that promotes resilience through end-of-life, there is a perception that DNR may hasten self-reflection and community building. In particular, death. Furthermore, because hospitals use DNR as a we will discuss the use of a Balint group and explore way of documenting expected deaths, DNR can some- how this model for physician support can be modified times be used to hide poor quality care. for palliative care clinicians in training. Metrics in Palliative Medicine. Currently there are over Finally, we will explore the use of group process and 300 quality metrics within the field of Palliative Medi- peer-mentoring after fellowship across geographic set- cine. However, these metrics are not prioritized and tings to help faculty prevent burnout and increase there are few guidelines for logistics of what needs to engagement and sustainability. In our case, an interdis- be measured, frequency, reporting, and how to mea- ciplinary group of four engage in an online professional sure. Specifically the quality metric of weight loss espe- group, meeting monthly to maintain our supportive re- cially in nursing homes, creates conflict and a push for lationships, discuss complex clinical issues we are strug- placement of feeding tubes at the end of life. gling with, and celebrate our professional and personal successes. We are tracking our own burnout scores to see if there is a correlation between participation in such a group and degree of stress and burnout. Paper Sessions

The Unintended Consequences of Quality Characterization of Deaths Within a Free- Metrics (FR418) Standing Children’s Hospital: Where Can Christine Toevs, MD, Terre Haute Regional Hospital, Palliative Care Focus Their Efforts? (FR419B) Terre Haute, IN. Robert M. Taylor, MD FAAHPM, Amy Trowbridge, MD, Seattle Children’s Hospital, Se- The Ohio State University, Columbus, OH. Francis attle, WA. Jennifer Walter, MD MS PhD, University of L. Mueller, MD FAAFP FAAHPM, Sutter Santa Rosa Pennsylvania, Philadelphia, PA. Eric McConathey, BS, Regional Medical Center, Santa Rosa, CA. Arif Kamal, Children’s Hospital of Philadelphia, Philadelphia, MD MHS MBA FAAHPM, Duke Cancer Institute, PA. Chris Feudtner, MD MPH PhD, The Children’s Durham, NC. Hospital of Philadelphia, Philadelphia, PA. Objectives Objectives Evaluate the consequences of quality metrics and Gain a deeper understanding of current practices the goals of Palliative Medicine. at the end of life in children’s hospitals. 358 Schedule With Abstracts Vol. 53 No. 2 February 2017

List several factors that may influence the charac- James Kirkpatrick, MD, University of Washington, Se- teristics of patients’ end of life, and present a hy- attle, WA. Keith Swetz, MD MA FACP FAAHPM, Uni- pothesis on why. versity of Alabama at Birmingham, Birmingham, AL. Compare data presented to their personal experi- Elizabeth Blume, MD, Boston Children’s Hospital, ence, and apply newly gained information to Boston, MA. Beth Kaufman, MD, Lucile Packard Chil- future research, teaching, and clinical practice. dren’s Hospital Stanford, Palo Alto, CA. Original Research Background. Our knowledge Objectives about the circumstances of overall in-hospital pediat- Describe the current attitudes of pediatric cardi- ric deaths is incomplete. Most published studies are ologists and cardiac surgeons towards palliative either focused on neonatal or pediatric intensive care for children with heart disease. care units, or rely on billing data that does not provide Identify perceived barriers to palliative care sufficient detail. Research Objectives. consultation for children with heart disease. 1.Determine frequencies of Original Research Background. As availability of types of deaths at a free-standing children’s hospital. palliative care (PC) consultation for children with 2.Describe patient- and hospital- level factors associ- advanced heart disease (AHD) increases, little is ated with circumstances of death. Methods. known about pediatric cardiologist attitudes towards Retrospective chart review recording de- PC. mographics, diagnoses, lengths of stay, location of Research Objectives. To describe perspectives of death, and palliative care involvement for all deceased cardiologists regarding PC for children with AHD. patients at CHOP between July 2011 and June 2014. Methods. Cross-sectional email-based survey of pedi- Based on review of patient charts, each patient was as- atric cardiologists from 18 pediatric medical centers signed to one of five ‘‘types’’ of death: failed resuscita- in June 2016. tion, withdrawal of life-sustaining therapy (WLST), Results. 122 physicians completed the survey (27% non-escalation, code event followed by withdrawal, or response rate). Respondents had a median of 19 years brain death. These categories were determined using of experience since medical school graduation (range an iterative process by experts on the research team. 7-49) and most practiced at academic medical centers Descriptive statistics were calculated. Results. (89%). Thirty-two percent reported having received Sample included 579 deceased patients. Sixty formal didactic training in PC and 20% reported hav- percent were under one-year of age, and 49% were fe- ing received didactic training in caring for children male. The most common locations of death were the with AHD at end-of-life. Fifty-nine percent of respon- Pediatric ICU (30%) and Neonatal ICU (32%). With- dents felt that PC consultations occur ‘‘too late;’’ yet, drawal of life-sustaining therapy (WLST) was the most a large majority (89%) ‘‘strongly agreed’’ or ‘‘agreed’’ common type of death (40%), followed by non-escala- that PC consultations are helpful. Barriers to request- tion (25%). Failed resuscitation was most common ing PC consultation were ‘‘few’’ to ‘‘somewhat’’ com- among black patients (45%) while WLSTwas most com- mon (72%) frequently described as, ‘‘referring to PC mon among white patents (42%). Of patients with palli- services too early will undermine the parents’ hope’’ ative care involved (32%), they were most likely to have (46%) and ‘‘concern that parents will think I am giv- non-escalation (57%) and least likely to have a code ing up on their child’’ (58%). Only 33% of cardiolo- event followed by withdrawal (3%). Conclusion. gists reported feeling ‘‘very’’ competent in caring for In a major children’s hospital most a child with AHD at end-of-life, while 34% felt ‘‘moder- deaths occur in ICUs. Race and whether palliative ately,’’ 21% ‘‘somewhat,’’ and 13% ‘‘a little’’ or ‘‘not at care were involved may affect the manner of a child all’’ prepared. death. Conclusion. Implications for research, policy or practice. Pediatric cardiologists report that PC consultations for their patients are helpful but tend Although improvements have been made regarding to occur too late. Perceived barriers to PC consultation pediatric in-hospital end of life care, further opportu- include concern that PC services will undermine nities for improvement clearly exist and should be parental hope and suggest that physicians are giving pursued. up. Perceived competency in caring for patients at end-of-life varies. Implications for research, policy or prac- Pediatric Cardiologist Attitudes About tice. Research is needed to define ways to facilitate Palliative Care (FR419C) earlier PC consultation for children with AHD and Emily Balkin, MD, University of California San Francis- overcome the perception that PC is incongruent co, San Francisco, CA. Joanne Wolfe, MD MPH with life-sustaining care. Understanding the attitudes FAAHPM, Dana-Farber Cancer Institute, Boston, MA. of cardiologists and perceived barriers to PC Vol. 53 No. 2 February 2017 Schedule With Abstracts 359

involvement will help inform future research and provide accurate resources as early as possible and educational efforts. stop using the terminology ‘‘incompatible with life’’. Additionally, the health care team can promote a pos- Lasting Legacy: Maternal Perspectives on itive experience by identifying opportunities for Perinatal Palliative Care (FR419D) normalization of prenatal and newborn care. Finally, Heidi Kamrath, DO FAAP, University of Minnesota, the importance of legacy formation was a strong Minneapolis, MN. Susan O’Conner-Von, PhD RN-BC theme which was unique in expression between study CHPPN, University of Minnesota, Minneapolis, MN. participants including but not limited to rituals, Jennifer Needle, MD MPH, University of Minnesota, research participation and value of the child’s life Minneapolis, MN. Erin Osterholm, MD, University of beyond time. Minnesota, Minneapolis, MN. Thomas George, MD, University of Minnesota, Minneapolis, MN. Rachael Stover-Haney, MSW LICSW, University of Minnesota The Discussion to Ensure the Patient- Masonic Children’s Hospital, Minneapolis, MN. Centered, Health-Focused, Prognosis- Appropriate, and Rational Medication Objectives Regimen (DE-PHARM) Quality Identify themes important to women offered peri- Improvement ProjectdRational natal palliative care during pregnancy. Deprescribing in Residents with Life- Identify practice change opportunities based on Limiting Illness (FR420A) the themes identified. Original Research Background. Jennifer Pruskowski, PharmD, University of Pittsburgh Many life-limiting School of Pharmacy, Pittsburgh, PA. Steven Handler, conditions can be diagnosed prenatally which allows MD PhD, University of Pittsburgh, Pittsburgh, PA. for perinatal palliative care planning as an option. This study is one of the first to explore the maternal Objectives experience of receiving a life-limiting diagnosis during Discuss the current dilemma of potentially inap- pregnancy. propriate medications for patients with life- Research Objectives. The aim of this project is to limiting illnesses. explore the maternal perspective after being offered Introduce one model for the implementation of de-prescribing. perinatal palliative care following the prenatal diag- Background. nosis of a life-limiting diagnosis for their fetus. There are many evidence-based guide- Methods. In a prior retrospective chart review, our lines for the initiations of medications, however few group identified 27 mothers who were offered peri- to discontinue. This unbalanced equation leaves natal palliative care, 18 chose perinatal palliative many potentially inappropriate medications, or poly- care and 9 did not. In this mixed methods study, these pharmacy, in patients with life-limiting illnesses. The women were invited to take part in focus groups or in- Discussion to Ensure the Patient-centered, Health- terviews as well as complete a survey on prenatal and focused, prognosis-Appropriate, and Rational Medica- infant end of life care and the validated Complicated tion regimen (DE-PHARM) quality improvement proj- Grief Assessment. Focus group and interview text ect is the first palliative care clinical pharmacist driven analysis were simultaneous and continuous. In addi- de-prescribing model for long-term care residents. tion to investigator analysis, ALTAS-TI software was Objective. The objective of this study was to de-pre- utilized. scribe medications via accepted recommendations Results. Of the 27 participants invited, 5 participated from clinicians. in a focus group and 2 completed phone interviews. Methods. This is a UPMC Quality Assurance/Per- Focus group and interview text analysis identified formance Improvement (QAPI) board approved several main themes including the importance of project. Phase I of this project occurred between comprehensive care, normalization of experience October 2015 and March 2016. To be eligible for and legacy formation. this project, residents had to be residing in the Conclusion and Implications for Practice. This UPMC Heritage Place Senior Community, receiving novel study identifies common themes among long-term (custodial care), and had previously mothers who contemplated perinatal palliative care noted a comfort-focused treatment plan (defined during pregnancy from which important implications as a POLST designation of DNR/DNI and either for practice are described. The theme of care incor- CMO or LAI). The palliative care clinical pharmacist porates participant appreciation for expert care and then completed an extensive chart review, incorpo- empathy as well as the strong recommendation rating the Holmes’ model for rational prescribing, from study participants that medical professionals and extrapolation of current evidence-based 360 Schedule With Abstracts Vol. 53 No. 2 February 2017

literature, to target medications for de-prescribing. doses as an adjunct to opioid pain management for Recommendations were sent to clinicians via email acute and chronic cancer-related pain. Demographic with a desired 120 day response time. information, clinical variables, and patient outcomes Results. There were 47 residents that met inclusion were abstracted from the records. criteria. Most were female (N¼43, 88%), were a Results. The median starting dose of Ketamine was mean age of 87.5 years. Seventy-two (72%) of residents 2mg/hr (range 1-4mg/hr) and the median ending were diagnosed with dementia. On averages residents dose was 12mg/hr (range 2-24mg/hr). Patients were has a total of 9.63 scheduled medications, and 5.38 as treated with ketamine for a median of seven days needed medications. Thirty-nine recommendations (range 1-18 days). The median opioid dose prior to were given by the palliative care clinical pharmacist initiating Ketamine was 532mg Morphine equivalent (range of 0-5/patient). Ten (26%) of recommenda- (IVME) (range 45-9420mg IVME) and after comple- tions were accepted, while 19 (38%) were not re- tion was 288mg IVME (range 10-3699mg IVME). sponded to and 3 (7%) recommendations were The median numeric pain scores before and after Ke- rejected. tamine infusion were not significantly different (7 vs Conclusion. The DE-PHARM may be a feasible, palli- 6). Ketamine was largely well tolerated, and the ative care clinical pharmacist driven, de-prescribing most commonly reported side effect was model for patients with life-limiting illnesses. hallucinations. Implications for Practice, Policy and Re- Conclusion. Patients who received Ketamine in our search. There is a need to develop formal de-prescrib- cancer center had severe pain despite receiving high ing models to reduce potentially inappropriate medi- dose opioids (22 mg IVME/h). In this population of cations to improve a patient’s quality of life and patients with intractable cancer pain, the addition of care. Ketamine was associated with 46% opioid dose reduc- tion with some improvement in analgesia. Implications for research, policy or prac- Ten Year Review of Intravenous Ketamine in tice. Further research into the appropriate use of Ke- the Treatment of Cancer-Related Pain tamine in this population is warranted. (FR420B) Jessica Goldberg, MSN MS NP, Memorial Sloan Ketter- ing Cancer Center, New York, NY. Jason Meadows, MD, Pilot Study of Minocycline for the Prevention Memorial Sloan-Kettering Cancer Center, New York, of Paclitaxel-Associated Neuropathy: NY. Lauren Koranteng, PharmD, Memorial Sloan-Ket- ACCRU RU221408I (FR420C) tering Cancer Center, New York, NY. Natalie Moryl, Deirdre Pachman, MD, Mayo Clinic, Rochester, MN. MD, Memorial Sloan Kettering Cancer Center, New Travis Dockter, MS, Mayo Clinic, Rochester, MN. Patri- York, NY. cia Zekan, MD, Novant Health/Forsyth Regional Can- Objectives cer Center, Winston-Salem, NC. Briant Fruth, BS, Articulate the role of Ketamine in the manage- Mayo Clinic, Rochester, MN. Kathryn Ruddy, MD, ment of cancer-related pain in an opioid-tolerant Mayo Clinic, Rochester, MN. Lauren Ta, DDS PhD, patient. Mayo Clinic College of Medicine, Rochester, MN. Wil- Evaluate the effectiveness and safety of Ketamine liam Sikov, MD FACP, Women and Infants Hospital of as a co-analgesic in treating cancer-related pain. Rhode Island, Providence, RI. Charles Loprinzi, MD, Original Research Background. Ketamine can be Mayo Clinic, Rochester, MN. Todor Dentchev, MD, Al- used as an analgesic for severe cancer pain when tru Health System, Grand Forks, ND. Nguyet Anh Le- opioid side effects preclude dose escalation and other Lindqwister, MD, Illinois CancerCarePeoria, Peoria, analgesics are not effective or are contraindicated. IL. The effectiveness and tolerability of Ketamine in can- Objectives cer patients has not been consistently demonstrated Understand the results of this pilot study of min- in the literature. ocycline for the prevention of P-APS and CIPN. Research Objectives. Therefore, we conducted a Gain knowledge of the potential effect of minocy- retrospective review of the use of Ketamine infusions cline for prevention of fatigue in patients treated at our institution over the past ten years to identify with paclitaxel. its effects on opioid requirements, pain control, and Original Research Background. Paclitaxel is associ- reported side effects. ated with both an acute pain syndrome (P-APS) and Methods. From 2004 to 2014, Ketamine was used in chronic chemotherapy-induced peripheral neuropa- the inpatient population in 201 cases. Of these, a total thy (CIPN). Preliminary animal data suggest that min- of 157 patients had admissions where they received ocycline may be effective for the prevention of intravenous (IV) Ketamine infusions at sub-anesthetic chemotherapy-induced neurotoxicity. Vol. 53 No. 2 February 2017 Schedule With Abstracts 361

Research Objectives. The primary goal of this study Original Research Background. Methadone’s effect was to obtain pilot data regarding the possible effect on QTc in cancer pain patients is not well known. The of minocycline on the prevention of paclitaxel- lone published study may not represent all palliative induced CIPN and P-APS, to determine if conducting prescribing patterns. a larger phase III placebo-controlled trial was Research Objectives. The objective of this study is to indicated. describe and characterize the effect of low-, moderate-, Methods. Patients with breast cancer were enrolled and high-dose methadone on QTc in cancer patients. prior to initiating neoadjuvant or adjuvant weekly Methods. This retrospective cohort study was exempt paclitaxel for 12 weeks. They were randomized to from IRB. Cancer patients with an order for enteral receive minocycline 200mg on day 1 followed by methadone over a 27-month period were included. 100mg twice daily or a placebo, with the same dosing Participants were divided into three methadone daily schedule. Patients completed 1) an acute pain syn- dose groups: <30mg (low-dose), 30 to 59mg (moder- drome questionnaire daily during chemotherapy, ate-dose), >60mg (high-dose). Primary outcome was and 2) the EORTC QLQ-CIPN20 questionnaire at the incidence of QTc prolongation in each group. Sec- baseline, prior to each dose of paclitaxel, and monthly ondary outcomes included change in QTc from base- for 6 months post treatment. Scores obtained from pa- line to study electrocardiogram (ECG), incidence of tient questionnaires were converted to a 0-100 scale, clinically significant QTc prolongation (> 500ms), where higher scores ¼ better quality of life. and prevalence of adverse cardiac outcomes including Results. Forty-seven patients were randomized, 45 of Torsades de Pointes. which were evaluable, with a mean age of 55. There Results. A total of 203 of 430 met the inclusion were no remarkable differences noted between the criteria for the study; low-dose: 91 patients (45%), two groups for the overall sensory score of the moderate-dose: 52 (26%), and high-dose: 60 (29%). EORTC-CIPN 20 or its individual sub-questions, Incidence of QTc prolongation for low-, moderate-, which evaluated tingling, numbness, or shooting and high-dose groups was 50 (55%), 37 (71%), and burning pain in hands and feet. However, there was 43 (72%), respectively (p¼0.039). Incidence of clini- a significant difference in the daily average AUC cally significant QTc prolongation was 10 (11%), 4 pain score attributed to P-APS, favoring minocycline (8%), and 7 (12%) for low-, moderate-, and high- (median 96.0 vs 84.3; p¼0.02). Correspondingly, pa- dose groups. Median change in QTc interval from tients receiving minocycline used less opioid pain baseline to study ECG for low-, moderate-, and high- medications for control of P-APS (0% vs 23%, dose groups was 6ms, 18ms, 14.5ms, respectively P¼0.05). Not only were no increased toxicities re- (p¼0.068). Sixty-two percent of patients in the moder- ported with minocycline, but there was an apparent ate-dose group and 67% of patients in the high-dose improvement in fatigue (median AUC 76.7 vs 59.0; group without QTc prolongation at baseline had P¼ 0.02). QTc prolongation at study ECG. Conclusion. Based on the results of this pilot study, Conclusion. Our data suggest there may be a higher minocycline did not appear to be beneficial for the pre- incidence of QTc prolongation in patients using oral vention of CIPN, but did look promising for reducing methadone in the cancer population than previously P-APS. Further study of this effect maybe warranted. defined in the literature. Implications for research, policy or practice: Further studies are needed to determine risk of adverse car- Evaluation of QTc Interval Prolongation diac effects in the cancer population and determine Among Cancer Patients Using Oral appropriate use and monitoring of methadone for Methadone (FR420D) pain management. Amanda Lovell Optum Hospice Pharmacy Services, Dublin, OH. Bridget McCrate Protus, PharmD CGP 1:30e2:30 pm CDP, Optum Hospice Pharmacy Services, Dublin, OH. Amber Hartman, PharmD, The Ohio State Uni- Concurrent Sessions versity Wexner Medical Center, Columbus, OH. Maureen Saphire, PharmD, Optum Hospice Phar- macy Services, Dublin, OH. The Practice of Palliative Medicine in Objectives Developing CountriesdPart Two (FR430) Describe the incidence of QTc prolongation in Cornelius Huwa, MBBS Mphill PallMed PGDip cancer patients taking oral methadone. PallMed HIVFe, Palliative Care Support Trust, Malawi, Discuss the effect of increasing methadone doses Africa. Seema Mishra, MD, AIIMS, New Deli, India. on QTc prolongation in cancer patients. Mohammad Shahinur Kabir, MBBS MPH Dip 362 Schedule With Abstracts Vol. 53 No. 2 February 2017

PallMed, Hospice Bangladesh Limited, Mohammad- states to develop and implement a Physician Orders pur, Bangladesh. Ahmad Mustafa Mehran, MD, Wazir for Life-Sustaining Treatment (POLST) paradigm pro- Mohammad Akbar Khan Hospital, Kabul, gram in accordance with nationally standardized core Afghanistan. requirements.’’ The National POLST Paradigm sets Objectives those core requirements and works to ensure that in- Learn how physicians in specific countries pro- dividuals with serious advanced illness or frailty not vide palliative care to their patient populations only have access to POLST Paradigm forms but to pro- often with limited resources. fessionals who understand the value of POLST and are Understand specific cultural and political chal- trained to have meaningful goals of care conversations lenges to developing palliative care clinical, to elicit and document patient treatment wishes prop- educational and research programs. erly on a POLST Paradigm form, as well as profes- Describe roles of different health care providers sionals who will honor them. practicing palliative care and how they meet the Since its inception in 1994, the POLST Paradigm has needs of their local populations. grown exponentially and now exists, at some level, in Please join AAHPM’s International Scholars for a 49 states, creating an intense need for education and panel discussion. Each scholar will present for 10- resources to help facilities and professionals appropri- 15 minutes on the state of the practice of palliative ately use POLST Paradigm Forms. Used appropriately, care in their home country, with an emphasis on these actionable medical order forms potentially avoid the roles of physicians, nurses, and other health- unwanted hospitalizations and emergency department care providers; the status of education and research visits and achieves the triple aim. Patients have peace in the field; and the unique challenges facing pa- of mind that their wishes are known and will be hon- tients and providers. There will be time allotted af- ored during a medical emergency. ter each presentation to field questions and In this concurrent session, a toolkit created in partner- dialogue from the audience. Prepare to be ship with the Pew Charitable Trusts will be presented. educated and inspired by these accomplished indi- Using POLST to Honor Patient Wishes Across the viduals who are leading and advancing the field Care Continuum will help facilities implement the of hospice and palliative medicine in their coun- Paradigm by addressing the needs of specific patient tries of origin. populations and professionals in primary care offices, hospitals, nursing homes and hospice facilities. In addition to educating about the benefits and value Using the POLST Paradigm to Honor of the POLST Paradigm (including how it differs Patient Wishes Across the Care Continuum: and complements advance directives as well as how it Presenting a Comprehensive Toolkit fits within advance care planning), the toolkit provides Designed to Help Health Care Professionals setting-specific resources for POLST Paradigm imple- and Facilities Implement the POLST mentation to address the specific needs of implement- Paradigm (FR431) ing POLST in different types of care facilities. Amy Vandenbroucke, JD, National POLST Paradigm, Portland, OR. Patricia Bomba, MD BA FACP, Lifetime Joining Forces with Geriatrics: Palliative HealthCare Companies, Rochester, NY. Kathryn Bor- Care Initiatives in the HRSA Geriatric genicht, MD HMDC, Bozeman Health Hospital, Boze- Workforce Enhancement Program, man, MT. Collaborating to Lead Change (FR432) Objectives Maura J. Brennan, MD HMDC FAAHPM, Baystate Review advance care planning and define the dif- Health, Springfield, MA. Ana Tuya Fulton Care New ferences between advance directives and the England Health Systems, Providence, RI. Shaida Tale- POLST Paradigm. breza, MD HMDC FAAHPM, University of Utah, Salt Identify challenges to POLST Paradigm imple- Lake City, UT. Delores Thomas-Rodriguez, RN mentation in nursing home, hospice, primary CHPN, BVNAH, Springfield, MA. care offices and hospitals. Objectives Illustrate appropriate clinician training, public Select one or more of the geriatrics-palliative education, policies and procedures in nursing collaborative models of care discussed in the ses- homes, hospice and primary care offices to sion to adapt and try following return home ensure patient POLST Paradigm orders are eli- within 6 months. cited, known and honored. Choose one or more educational programs/tools A key recommendation from the Institute of Medi- to adapt and apply within 6 months after return cine’s (IOM) Report Dying in America is to ‘‘encourage home from the annual meeting. Vol. 53 No. 2 February 2017 Schedule With Abstracts 363

Palliative Care and Geriatrics share a holistic, patient- Describe how individuals can access mentors and centered approach; both care for vulnerable patients/ the mutual benefits that mentors and mentees families, work in interprofessional teams and struggle can derive from a mentor-mentee relationship. in a ‘‘fee for service’’ world. Most palliative care patients The field of palliative care is taking traction in main- are older; geriatric patients are often in their last years of stream medicine, with a growing role to play in patient life and frequently frail and suffering. Geriatricians will care. Critical to narrowing the widening gap between fail without excellent palliative care skills; palliative workforce shortage and projected demand for hospice care clinicians will be unable to fully support their older and palliative medicine providers is expanded access patients without a solid grasp of geriatrics. Clearly, the to and engagement in education and training. There two specialties need to collaborate closely educationally, are many challenges to meeting the educational needs clinically and in leading system’s change. of learners, including the diversity of professional In June 2015, HRSA awarded $37.5 million over 3 years backgrounds and experience of those involved, rela- to 44 new Geriatrics Education Centers across the tive youth of the field, multiplicity of career paths nation. The overarching goal is to improve the care prior to engaging in hospice and palliative medicine, of elders by better incorporating geriatrics practices varied care settings and population needs, function into primary care while simultaneously developing the as an effective team member, cultural differences interprofessional work force. Securing community and the intricacies of teaching the human dimension engagement and meeting the needs of disadvantaged of care. Despite the broad range and variation of these patients and those with dementia are key themes. challenges, they all relate to individualsdthose who Over 1/3 of successful GWEP applicants have incorpo- led the way, those currently at the forefront and the rated palliative care educational and clinical initiatives myriad doing our daily work. into their projects. This will be the only major federal In this interactive session, we will take a broad look at the funding for geriatrics in the coming years; it is critical role of mentoring in the development of our field. The to leverage this opportunity and learn from this experi- panelists, two medical oncologists, a geriatrician and a ence. Thus far, the GWEP roll out has received little psychiatrist, all experienced palliative care clinicians, attention within the palliative care field. will start with a discussion of the different roles that This session will explore the full range of palliative mentors, coaches and sponsors play in professional, GWEP initiatives. The moderator will introduce the team and program development. Panelists, who com- background to the GWEP geriatrics-palliative care col- bined have a broad mentorship experience in clinical laborations and panelists will briefly describe current care, program development, research, public policy projects in several categories while identifying target and resiliency, will offer their perspectives on what learners, sites of care, clinical/educational methods makes a good mentor-mentee relationship, mutual ben- and special patient populations. Attendees will then efits of mentoring for the mentor and mentee and how rotate freely among breakout tables exploring projects to ‘‘get the most’’ from your relationship. There will be devoted to: nursing home care, curricular innovations, ample time for discussion among session participants patients with dementia, home/hospice care and primary and panel members. By the end of the session, it is antic- care/community initiatives. Attendees will plan how to ipated that participants will have an improved under- apply these new models to better collaborate with geriat- standing of the role that mentorship can play in rics colleagues back in their home institutions. professional development, ways to access local and distant mentors and the mutual benefits of mentoring. Building Our Future by Mentoring One Another (FR433) Who Let the Dogs IN: Helping our Four Donna Zhukovsky, MD FACP FAAHPM, MD Anderson Legged Friends Visit at the Bedside (FR434) Cancer Center, Houston, TX. Eduardo Bruera, MD Rodney Tucker, MD MMM FAAHPM, University of FAAHPM, MD Anderson Cancer Center, Houston, Alabama at Birmingham Center for Palliative and Sup- TX. Diane Meier, MD FACP FAAHPM, Icahn School portive Care, Birmingham, AL. Ashley Nichols, MD, of Medicine at Mount Sinai, New York, NY. Gary Rodin, University of Alabama at Birmingham Hospital, Bir- MD, Princess Margaret Cancer Centre, Toronto, ON. mingham, AL. Paul Tatum, MD CMD AGSF MSPh Objectives FAAHPM, University of Missouri, Columbia, MO. Eliz- Identify the multiple areas in which mentoring abeth Byrd, MSN RN CCNS, University of Alabama at can play a role in the development of hospice Birmingham, Birmingham, AL. and palliative medicine. Objectives Differentiate among the roles that mentors, spon- Articulate the benefits of allowing pet compan- sors and coaches can play in professional, team ions to visit loved ones in palliative care inpatient and program development. settings. 364 Schedule With Abstracts Vol. 53 No. 2 February 2017

Describe the necessary steps to ensure compli- quality care. The authors will report on a thorough ance with infectious control barriers that may literature search from 2013-2016, presenting high impede allowing pet visitors to be with patients quality studies that add to the 2013 State of the and families. Science. Review a set of best case examples from other in- We will also present major findings of one author’s stitutions with formal pet visitor policies. qualitative study that sought to understand parents’ With the increasing number of inpatient palliative experiences of pregnancy with a lethal fetal and hospice units housed within the walls of acute diagnosis and parents’ needs from the health care care and skilled nursing facilities, it is an increasingly system. common request and practice to allow patient or We will also present major findings from the au- family pets to visit at the bedside of a loved one. thors’ work, including the only survey of PPC pro- Many facilities have relationships with organizations grams in the US, which reviewed structure, that have trained pet therapy or visitor groups that processes and outcome measures, and assessed comply with necessary training and regulation; how- how these aligned with the National Consensus ever, these visits do not replace the loving relation- Project domains of care. We surveyed PPC program ships that many of our patients have with their own representatives from 30 states (n¼75), using an on- animal family members. In inpatient acute care set- line cross-sectional survey design. We found that tings, there are multiple considerations that can 70% of programs are <10 years old. Programs become barriers to allowing patients to have their vary widely in setting (academic medical centers, pets visit, such as infectious disease protocols, poten- regional or community hospitals, local hospices, tial allergies or fear of animals on the part of staff, or community based organizations), programmatic issues to address pet hygiene, etc. This session will structure, and outcome measures. Formal quality focus on an increasingly common issue facing hospi- assessment measures are present in only 38% of tals and palliative care programs as we move toward programs. Nonetheless, program responses revealed more patient and family centered care. Presenters a consistent and pervasive philosophy of patient- will provide a review of the evidence that supports centered care. use of pets in the healthcare setting as well as mate- The authors will synthesize the results of these recent rials from over 10 institutions’ policies and proced- studies and the review of recent literature to offer ures for the audience, presenting it in a usable and both provider- and system-level recommendations for entertaining format. Strategies to advocate for pet practical clinical applications, and share with the audi- visitation polices that led to administrative buy-in ence a table of recommendations to take home to and culture change will be discussed. their own programs.

Caring for our Tiniest Patients: Taking the Planning Advance Care Together: Latest Research in Perinatal Palliative Care Implementing Advance Care Planning to Practical Clinical Applications (FR435) Practices Across an Academic Medical Erin Denney-Koelsch, MD FAAHPM, University of Ro- Center (FR436) chester, Rochester, NY. Charlotte Wool, PhD RN, York Erik Fromme, MD MSCRFAAHPM, Oregon Health & College of Pennsylvania, York, PA. Science University, Portland, OR. Seiko Izumi, PhD RN, Oregon Health & Science University, Portland, Objectives OR. Matthew Diveronica, MD, Oregon Health & Sci- Describe the methods of a comprehensive litera- ence University and VA Portland Health Care System, ture review. Portland, OR. Ellen Distefano, MN RN CEN, Oregon Describe needs of parents in the setting of lethal Health & Science University, Portland, OR. fetal diagnoses. Describe what is known about Perinatal Palliative Objectives Care Programs in the US. Describe barriers and facilitators to implementing Compared to other areas of research in palliative advance care planning practices in a large aca- care, the literature on perinatal palliative care demic medical center. (PPC) is sparse, but slowly growing. Some important Discuss strategies to implement advance care developments have occurred since the most recent planning practices in a large academic medical State of the Science, published in Wool, 2013. PPC center engaging all team members from various programs are increasing in number (over 200 world- disciplinary background, roles and functions. wide), though wide variation exists in setting, Discuss how to promote cultural shift incorpo- composition, and services, and there is little to rating advance care planning into the routine guide programs in what is standard practice and practice of every healthcare provider. Vol. 53 No. 2 February 2017 Schedule With Abstracts 365

Despite the increasing awareness about the impor- Describe when and how to use Advance Care tance of advance care planning (ACP) in public and Planning (ACP) codes. among healthcare providers, challenges to making Palliative Care (PC) programs are flourishing nation- ACP routine practice persist. This institution-wide ally, buoyed by a change in healthcare reimbursement initiative to implement ACP for all patients has models away from volume-driven fee-for-service care become our academic medical center’s top quality and toward payment for value. Under a value-based sys- improvement priority. Challenges the initiative’s steer- tem, cost avoidance, sometimes a byproduct of care ing group has faced include 1) reluctance of clinicians focused on patients’ goals, values, and preferences, to embrace ACP in their practice because of their no longer represents lost revenue to organizations. Un- confusion or misunderstanding about ACP, and 2) fortunately, cost avoidance is invisible on a balance different views, needs, and practice patterns associated sheet and clinical revenues are receiving more scrutiny with ACP among clinicians and staff in various disci- as health systems tighten their fiscal belts. To survive, plines, departments, and units. We employed a multi- PC programs must reach for opportunities to maximize pronged strategy to disseminate ACP practice revenue within the current reimbursement system to targeting a variety of clinician groups and units based limit health system or hospice program subsidies. on their interest, needs, and practice patterns. One of How can PC clinicians understand the complex world the learnings that guided our approaches is that ACP of healthcare billing and financing? In this interactive, must be a team effort. Educating and expecting one concurrent session, our group of PC clinicians and a profession to practice all aspects of ACP is neither nationally-recognized PC billing and coding expert effective nor sustainable. Each healthcare team mem- will integrate four articles we have written around ber who touches the patient in various stage of illness the Business of PC. After gathering audience mem- (including primary care providers, specialists, hospital- bers’ challenges with billing and coding in HPM, we ists, intensivists, nurses, social workers, and medical as- will offer background on the current and future sistants in outpatient clinics and hospitals) can play a healthcare reimbursement environment and focus role in facilitating ACP. We have used different ap- on changes, like MIPS and APMs, coming in the proaches tailored to different clinician groups and next 3 years due to MACRA. Our session will then units depending on the workflow and function of turn to program level opportunities we have encoun- the clinician in a particular setting. In this concurrent tered while consulting with dozens of PC programs session, we will describe models and tools we devel- in the last 2 decades, sharing 10 straightforward tips oped to clarify confusion, facilitate shared understand- to eliminate errors made in the inpatient and outpa- ing, and communicate about ACP within the tient PC settings. Advance Care Planning codes will healthcare team and patients and families. We will be thoroughly discussed as these represent a signifi- also share our experiences and lessons learned from cant new revenue source that dovetails perfectly with specific approaches we employed for different target the work of PC clinicians, allowing non-provider mem- groups (e.g., residents, attending physicians, nurses, bers of the IDT to be reimbursed for care. social workers, medical assistants). Upon completion of the session, participants will be better able to navigate payment changes coming in the future, remedy billing and coding mistakes com- The Future is Now: Overcoming Billing and mon in today’s practice, and implement or fine-tune Other Financial Challenges in Inpatient and new methods of clinical revenue generation to ensure Outpatient Palliative Care (FR437) their programs’ ongoing financial health. Christopher Jones, MD FAAHPM, Main Line Palliative Care, Radnor, PA. Arif Kamal, MD MHS MBA FAAHPM, Duke Cancer Institute, Durham, NC. Jean I Can’t Stop the Dancing: Management of Acevedo, CHC CPC LHRM CENTC, Acevedo Consul- Restless Leg Syndrome in Hospice Care ting Inc., Delray Beach, FL. Janet Bull, MD HMDC (FR438) FAAHPM, Four Seasons, Flat Rock, NC. Martina Meier, MD, Providence TrinityCare Hospice, Objectives Los Angeles, CA. Mary Lynn McPherson, PharmD Discuss how the Medicare Access and CHIP Reau- BCPS CPE, University of Maryland School of Phar- thorization Act of 2015 (MACRA) will impact macy, Baltimore, MD. Eric Prommer, MD HMDC Palliative Care program revenues through imple- FAAHPM, Greater Los Angeles Healthcare, Los An- mentation of Merit-Based Incentive Payments geles, CA. Jessica Besbris, MD, Cedars-Sinai Medical (MIPS) and Alternative Payment Models (APMs). Center, Los Angeles, CA. Describe 5 common misunderstandings palliative Objectives care clinicians have of clinical reimbursement for Discuss how to evaluate the patient with restless Medicare patients. leg syndrome. 366 Schedule With Abstracts Vol. 53 No. 2 February 2017

Discuss how to use a wide variety of analgesics in these qualities, giving rise to burnout, compassion restless leg syndrome. fatigue and hopelessness. Identify the augmentation syndrome in the rest- Describe practical and effective contemplative less leg syndrome. and self-reflective practices that connect us to Restless legs syndrome (RLS), also referred to as Willis- our innate qualities and help us be more resilient Ekbom disease (WED), is a chronic neurological disor- in the face of overwhelming challenges and der that is lifelong, distressing and unfortunately be- emotions. comes a frustrating symptom in patients with Complete 3 brief exercises including mindful- advanced illness. RLS is a circadian disorder of sen- ness, breath work and a self-reflective writing/sto- sory-motor integration manifested by an urge or a rytelling exercise that help connect us to our need to move the limbs to stop unpleasant sensations resilience, compassion and hope in challenging in the evening or while at rest. Consisting of specific situations. diagnostic criteria, symptoms usually occur in the legs, Burnout, compassion fatigue and hopelessness are but can become generalized. As the disease worsens, important issues facing our palliative care clinicians the circadian pattern can be overridden and symptoms at all levels of training and practice. Compassion, may be present 24 hours a day (augmentation). RLS is resiliency and hope are innate qualities, which are found in many diseases encountered by the palliative nurtured through mindfulness, and contemplative care physician including renal failure and Parkinson’s and self-reflective practices. The arts and humanities disease. Iron dysregulation plays a role in its pathogen- create a safe space for our emotions to be expressed esis. The impact of RLS on sleep, particularly sleep-onset and understood. Without the nurturance of our insomnia, contributes to the overall adverse impact on innate qualities that give us deep satisfaction and quality of life, often leading to serious psychosocial meaning in our work, clinicians become increasingly impairment. Disturbed sleep is usually the primary vulnerable to emotional exhaustion. Working with reason a patient seeks medical attention. Additionally, our own and others grief and loss are a critical there is also a strong association between untreated component of healthy PC teams and practitioners. RLS and depression. Therapy includes pharmacologic Palliative care is demanding. What are the practices approaches and preventive measures as well as a wide va- that are effective yet practical in our busy practices? riety of drug therapies including dopamine agonists, cal- Burnout alone, in a recent study, affected 62% of cium channel alpha-2-delta (a2d) ligands, opioids and PC physicians. This session will discuss what condi- even iron therapy. Augmentation or worsening of symp- tions disconnect us from our innate qualities that toms can occur and must be recognized. Loss of medica- called us to palliative care. What is the nature of tion effectiveness occurs. A multidisciplinary team of our calling to PC service? What sustains us in chal- pharmacists, neurologists and palliative care specialists lenging times? How do we care for ourselves when will enable the attendees to become proficient in the emotions feel overwhelming? What new practices management of this troublesome syndrome. can we incorporate into our daily lives to nurture The session will enable attendees to and sustain us? This session will explore the nature 1.) Efficiently evaluate the patient with RLS; of calling, our innate qualities, what disconnects us 2.) Understand proper dosing and scheduling of from our true selves, how narrative medicine con- medications; nects us to relationship and meaning, how we can 3.) Recognize and manage augmentation and promote healthy emotions, and how mindfulness loss of medication efficacy. and self-reflective practices help us connect to our 4.) Treat insomnia associated with RLS and deepest selves and others so that resiliency, compas- 5.) Recognize other analgesic approaches in re- sion and hopefulness are our predominant state of fractory cases. An algorithm for treatment will being. be presented. Paper Sessions Compassion, Resiliency, and Hope: Nurturing Our Innate Qualities Through Is Symptom Burden Associated with Contemplative Practices (FR439) Advanced Care Planning in Individuals Lucille Marchand, MD BSN FAAHPM, University of Who Die of Cardiovascular Disease? Washington, Seattle, WA. Kevin Dieter, MD FAAHPM, (FR440A) Hospice of the Western Reserve, Cleveland, OH. Joy Goebel, PhD MN RN, California State University Objectives Long Beach, Long Beach, CA. Olga Korosteleva, Distinguish the innate qualities of compassion, PhD, California State University, Long Beach, CA. Eliz- resiliency and hope, and what separates us from abeth Ortega, MS, California State University, Long Vol. 53 No. 2 February 2017 Schedule With Abstracts 367

Beach, Long Beach, CA. Yemisrach Lodebo, MSc, Cal- approaches to improve rates of ACP in CVD should ifornia State University Long Beach, Long Beach, CA. target populations with low symptom burden. Timothy Manning, MS, California State University Long Beach, Long Beach, CA. Association of POST Form Use with Quality Objectives End-of-Life Care Metrics in Cancer Patients: Discuss Advance Care Planning approaches used Update from the West Virginia Registry by cardiovascular disease decedents in a nation- (FR440B) ally representative sample. Sandra Pedraza, MD, West Virginia University School Identify significant symptoms experienced in the of Medicine, Morgantown, WV. Mark Knestrick, MD, last year of life for decedents of cardiovascular West Virginia University School Of Medicine, Morgan- disease. town, WV. Stacey Culp, PhD, West Virginia University, Describe the association of symptom burden with Morgantown, WV. Evan Falkenstine, BSBA, West Vir- the proclivity to engage in advance care planning ginia Center For End-of-Life Care, Morgantown, WV. in individuals dying of cardiovascular disease. Alvin Moss, MD FACP FAAHPM, West Virginia Univer- Original Research Background. The unpredictable sity School of Medicine, Morgantown, WV. disease trajectory for persons dying from cardiovascu- Objectives lar disease (CVD) may make planning for future care Understand the impact of the use of POST forms challenging. In addition, research suggests these indi- in advanced cancer patients. viduals may suffer with significant symptomatology in Identify the potential for a statewide POLST late life. Paradigm program to improve respect for Research Objectives. To describe symptom burden advanced cancer patients’ end-of-life treatment and advance care planning (ACP) in individuals dying preferences. of CVD, and examine the association between symp- Original Research Background. The West Virginia tom burden and ACP in this population. Physician Orders for Scope of Treatment (POST) Methods. A cross-sectional design using Health form, a POLST Paradigm form (www.polst.org), trans- Retirement Survey 2002-2012 data (a nationally repre- lates the preferences of patients with advanced illness sentative survey) addressed the research Objectives. for whom their physicians would not be surprised if Proxies were asked about decedent’s symptom burden they died in the next year into medical orders for sys- (experiences with significant pain, anorexia, depres- tem-level interventions. Few studies have evaluated sion, vomiting, confusion, and fatigue), and ACP activ- POST form use in cancer patients. ities (the presence of a durable power of attorney for Research Objectives. To compare the outcomes healthcare [DPOA], or a living will, or a conversation associated with POST form versus advance directive about care preferences at the end of life). Clinical and (AD) use on end-of-life care quality metrics in cancer demographic information was obtained. patients. Results. Complete data was available for 1304 dece- Methods. A retrospective study of West Virginians dents. Mean age at death was 85.75 (range 65-105, SD who submitted POST forms or ADs to the West Vir- 7.13); 37.5% died in hospitals, 27.8% died in skilled ginia e-Directory Registry and died from cancer be- nursing facilities, and 34.8% died at home or with hos- tween 1/1/2011 and 2/4/2016. pice. Decedents had a mean of 3.3 symptoms ‘‘most of Results. Of patients in the West Virginia e-Directive the time’’ in the last year of life (range 0-6, SD 1.69). Registry during the study period, 2159 patients died Pain (65.5%) and fatigue (62.4%) were the most com- from cancer: 1108 (51.3%) with ADs and mon symptoms. Proxies reported engaging in ACP (any 1051(48.7%) with POST forms. Of patients with type) with 78.0% of decedents, 60.3% reported the POST forms, 524 (49.9%) were admitted to hospice presence of a DPOA, 47.3% reported a living will, and compared to 299 (27.0%) with ADs (p<.001). In-hos- 56.5% reported a conversation about care preferences. pital death occurred in 310 (28.0%) with ADs Higher symptom burden was associated with all types of compared to 150 (14.3%) with POST forms; the unad- 2 2 ACP (DPOA: X ¼40.5, p<0.000; living will: X ¼ 28.91, justed odds ratio for an out-of-hospital death for pa- 2 p¼0.001; conversations: X ¼36.66, p<0.000; any type tients with POST forms compared to ADs was 2.33 2 of ACP: X :55.91, p<0.000). (p<.001). Of the 1051 POST forms, 41 oncologists Conclusion. In this sample, CVD decedents with completed 130 (12.4%), 22 palliative care physicians higher symptom burden were more likely to engage completed 355 (33.8%), and 286 primary care physi- in ACP. cians completed 566 (53.9%). Median time from Implications for research, policy or prac- POST form completion to death was 1 month. tice. Because ACP encourages care consistent with pa- Conclusions. Use of POST forms compared to tient preferences and improves patient satisfaction, advance directives in cancer patients is associated 368 Schedule With Abstracts Vol. 53 No. 2 February 2017

with higher achievement of two quality end-of-life Research Objectives:. Understand implementation care metrics: admission to hospice and out-of-hospi- of lay navigator-led ACP tal death. Greater oncologist use of the surprise Describe navigator self-efficacy in conducting ACP question as a trigger for end-of-life care conversa- before and after training tions and POST form discussions may result in Compare resource utilization (hospitalization, ICU ad- earlier POST form completion leading to higher missions) between cancer patients who did and did quality end-of-life care for patients with advanced not participate in navigator-led ACP cancer. Methods. A convergent, parallel mixed-methods Implications for research, policy or prac- study was used to evaluate implementation of a lay tice. Implementation of POLST programs in all navigator-led ACP program across 12 Southeastern states as recommended by the Institute of Medicine US cancer centers. Data collection included: (1) elec- will likely improve end-of-life care for cancer pa- tronic records of ACP conversations initiated, tients. declined, on-going, and completed (2) pre- and post-training surveys completed by navigators Implementation and Impact of Lay measuring navigator self-efficacy and knowledge Navigator-Led Advance Care Planning for (n¼45), and (3) Medicare claims-based patient out- Cancer Patients (FR440C) comes (n¼820) including hospitalizations, ICU admis- Gabrielle Rocque, MD, University of Alabama at Bir- sions, chemotherapy within last 14 days of life, and mingham, Birmingham, AL. James Dionne-Odom, hospice use. PhD RN, School of Nursing, University of Alabama at Results. Between 6/1/14-12/31/15, 50 navigators Birmingham, Birmingham, AL. Courtney Williams, were certified as Respecting ChoicesÒ First Steps MPH, University of Alabama at Birmingham, Birming- ACP Facilitators. Navigators initiated 1571 ACP con- ham, AL. Bradford E. Jackson, PhD, Research Institute, versations; 672 completed; 412 were on-going; 487 JPS Health Network, Fort Worth, TX. Richard Taylor, were declined. The mean score for feeling prepared DNP CRNP ANP-BC, University of Alabama at Birming- to conduct ACP conversations increased from 5.6/10 ham School of Nursing, Birmingham, AL. Maria Pisu, pre-training to 7.5/10 after training (p¼0.001). In PhD, University of Alabama at Birmingham, Birming- comparison to navigated patients declining participa- ham, AL. Edward Partridge, MD, University of Alabama tion in ACP (n¼167), there was a trend toward fewer at Birmingham, Birmingham, AL. Elizabeth Kvale, MD, hospitalizations (47% and 55%, p¼0.06) and ICU ad- University of Alabama at Birmingham Center for Palli- missions (17% vs 24%, p ¼ 0.05) 30 days prior to ative and Supportive Care, Birmingham, AL. Chao-Hui death for decedents engaging in ACP with navigators Sylvia Huang, PhD, University of Alabama at Birming- (n¼409). ham, Birmingham, AL. Soumya J. Niranjan, BPharm Conclusion. A navigator-led ACP program was able MS, University of Alabama at Birmingham, Birming- to be widely disseminated and may be associated ham, AL. Karina I. Halilova, MD, University of Alabama with lower rates of hospitalizations and ICU admis- at Birmingham, Birmingham, AL. Kelly M. Kenzik, sions near EOL. PhD, University of Alabama at Birmingham, Birming- Implications for research, policy or practice. Lay ham, AL. Linda A. Briggs, MSN MA RN, Gundersen navigator-led ACP conversations may hold promise Health System, La Crosse, WI. in cancer centers with limited palliative care resources. Objectives Further research is needed to understand training Understand implementation of lay navigator-led needs and improve the skills of navigators facilitating ACP. ACP. Describe navigator self-efficacy in conducting ACP before and after training. Compare resource utilization (hospitalization, ‘‘Our Life Is a Story, and We All Want a ICU admissions) between cancer patients who Good Ending to the Story’’: Navigators on did and did not participate in navigator-led ACP. Advance Care Planning Conversations in Original Research Background. The Institute of Older Patients with Cancer (FR440D) Medicine, American Society of Clinical Oncology, and Chao-Hui Sylvia Huang, PhD, University of Alabama at American Academy of Hospice and Palliative Medicine Birmingham, Birmingham, AL. Gabrielle Rocque, recommend that persons with serious, life-limiting MD, University of Alabama at Birmingham, Birming- illness engage in advance care planning (ACP), but im- ham, AL. Soumya Niranjan, BPharm MS CCRP, Uni- plementation is time-consuming for medical personal. versity of Alabama at Birmingham, Birmingham, AL. One potential solution for cancer patients is to delegate James Dionne-Odom, PhD RN, School of Nursing, ACP tasks to lay navigators. University of Alabama at Birmingham. Richard Taylor, Vol. 53 No. 2 February 2017 Schedule With Abstracts 369

DNP CRNP ANP-BC, University of Alabama at Bir- health literacy, fears, lack of readiness, and a ‘‘battle’’ mingham School of Nursing, Birmingham. Karina mentality. At the navigator level, established rapport Halilova, MD MPH, University of Alabama At Birming- was a necessary facilitator while personal discomfort ham, Birmingham, AL. Edward Partridge, MD, Univer- and timing issues were barriers. System facilitators sity of Alabama at Birmingham, Birmingham, AL. included physician engagement and oncology-team Elizabeth Kvale, MD, University of Alabama at Bir- consultation support. Barriers included lack of time mingham Center for Palliative and Supportive Care, and space, lack of stakeholder buy-in, and cultural Birmingham, AL. Courtney P. Williams, MPH, Univer- suspicion. sity of Alabama at Birmingham, Birmingham, AL. Conclusion. Navigators identified both facilitators Bradford E. Jackson, PhD, Research Institute, JPS and barriers related to facilitating advance care plan- Health Network, Fort Worth, TX. Kelly M. Kenzik, ning conversations with older cancer patients in PhD, University of Alabama at Birmingham, Birming- various cancer settings. Lay navigators identified ham, AL. Kerri S. Bevis, MD, University of Alabama several areas where additional training and infrastruc- at Birmingham, Birmingham, AL. Audrey S. Wallace, ture support might further enable ACP conversations MD MSN, University of Alabama at Birmingham, Bir- in patients with advanced cancer. mingham, AL. Nedra Lisovicz, PhD MPH CHES, Uni- Implications for research, policy or prac- versity of Alabama at Birmingham, Birmingham, AL. tice. Future work should explore design and evalua- Maria Pisu, PhD, University of Alabama at Birming- tion of healthcare delivery models to support navi- ham, Birmingham, AL. Linda A. Briggs, MSN MA gator-led ACP conversations, and evaluate outcomes RN, Gundersen Health System, La Crosse, WI. such as alignment between patient preferences and Objectives care received. Describe factors that function as facilitators of lay navigator facilitated ACP conversations. Interprofessional Teamwork When Meeting Describe factors that function n as barriers to lay with a Family in the Pediatric Cardiac navigator facilitated ACP conversations. Intensive Care Unit (FR441A) Identify impact of lay navigation and opportu- Jennifer Walter, MD MS PhD, University of Pennsylva- nities for future examination. nia, Philadelphia, PA. Emily Sachs Children’s Hospital Original Research Background. National guide- of Philadelphia, Philadelphia, PA. Aaron Dewitt, MD, lines endorse advance care planning (ACP) as essen- Perelman School of Medicine/Children’s Hospital of tial; however, few patients engage in such planning Philadelphia, Philadelphia, PA. Robert Arnold, MD due, in part, to pragmatic challenges in delivering FAAHPM, University of Pittsburgh, Pittsburgh, PA. ACP in cancer care settings. Little is known about Chris Feudtner, MD MPH PhD, The Children’s Hospi- whether certified lay navigators can facilitate ACP con- tal of Philadelphia, Philadelphia, PA. versations in older adults with cancer. Objectives Research Objectives. To describe facilitators and Identify the recommended roles of team mem- barriers associated with implementation of certified bers in conducting family meetings as presented lay navigator-led ACP discussions. in the literature and identify patterns of team Methods. Semi-structured interviews were conducted behavior in the pediatric critical care unit. at 11 Southeast cancer centers with 26 lay navigators Identify what constitutes empathic opportunities who were certified as Respecting ChoicesÔ First Steps and responses in a family meeting, how to assess ACP Facilitators. Interview topics included quality of parental understanding and understand the dif- ACP training, knowledge and comfort in having ACP ference between open and closed ended conversations, barriers and facilitators to conducting questions. ACP, and perceived role in navigating patients with Original Research Background. Parents of chil- advanced cancer. Audio-recorded interviews were tran- dren in the pediatric cardiac intensive care unit scribed verbatim and uploaded into NVivo 10 soft- (CICU) report inadequate communication and a ware; 2 primary coders identified themes using lack of empathy during conversations with their thematic analysis employing Nvivo coding. Inter-rater clinicians. agreement was assessed using Cohen’s Kappa Research Objectives. To evaluate communication (¼0.81, high agreement). behaviors and inter-professional team interactions Results. Navigators (n¼26) completed 672 ACP con- during family meetings in the pediatric CICU. versations. Three domains of Facilitators and Barriers Methods. Meetings of family members and CICU cli- emerged: patient, navigator, and system domains. At nicians were audio recorded. We used quantitative the patient level, prior experience with a family mem- case-coding to compare the duration of contributions ber was a facilitator while barriers included limited made by attendees, and used the SCOPE codebook to 370 Schedule With Abstracts Vol. 53 No. 2 February 2017

measure assessment of parental understanding, closed are limited studies on role of family participation and open-ended questions, and empathic statements in DCP and factors that predict family making in response to opportunities. Qualitative coding iden- the decisions for the patient receiving palliative tified major themes regarding content discussed in care. the meetings. Research Objectives. In this study we examined the Results. In the 10 meetings, CICU attendings spoke frequency, characteristics, and factors associated with for an average of 64% of each meeting (SD¼17%), family making the decisions for the advanced cancer parents 17% (SD¼12%), registered nurses 7% patients (ACP) receiving palliative care. (SD¼6%), social workers 3% (SD¼5%), and nurse Methods. Secondary analysis of a study to deter- practitioners 1% (SD¼1%). In two meetings, mine the decisional control preferences in an inter- parental understanding was assessed at the begin- national multicenter study involving patients ning of the meeting; in no meeting was this assessed receiving PC in USA, France, Spain, Brazil, Chile, at the end. Clinicians asked parents 132 closed- Argentina, Jordan, India, Philippines, Singapore ended questions (86%) and 21 open-ended ques- and South Africa. ACP receiving palliative care tions (14%). The team missed empathic opportu- were surveyed using the Decision Control Preference nities seven out of 17 (41%) occasions. CICU scale and Understanding of Illness questionnaire. attendings had the highest number of expressions Descriptive statistics and Logistic regression analysis of empathy at 12 (57%), followed by social workers was performed. at 2 (10%). Social workers were the team member Results. A total 1490 ACPs were evaluated. The me- most likely to initiate discussions about parents’ dian age was 58, 55% were female, 59% were mar- worries or concerns. Nurses’ contributions were ried, 36.2% were educated college or higher largely to clarify a CICU attending’s statement or degree. Shared, Active and Passive DCP were 33%, to elicit any questions about nursing from the 44% and 23% respectively. In 100/333 ACPs who ex- parents. pressed passive DCP chose family DC (100/1490, Conclusion. Clinical information is often given 6%). Logistic regression analysis shows that gender without checking for parental understanding but (OR 8.45, P¼0.004), age (OR .18, P¼0.009), ACP empathic opportunities were responded to frequently. who felt their cancer is curable (OR 3.49, Team members seem to serve different roles in the P¼0.038), and ACPs belonging to France and India meetings, with physicians speaking for two-thirds of were more likely to prefer family making the deci- the time. sions for them. Implications for research, policy or practice. To Conclusion. ACP preference to family making deci- optimize the results of family meetings for families, sions regards to their PC is uncommon. Lower age, fe- clinical team members may need to clarify core family male gender, country of origin and increased meeting tasks and coordinate their communication perception of curability more likely to significantly and supportive activities. predict family DCP. Implications for research, policy or prac- Patients Preference Regarding Family tice. Individualized understanding DCP is important Participation in Decision Making: A for optimal communication in PC, quality care and pa- Multicenter International Study (FR441B) tient satisfaction outcomes. Sriram Yennurajalingam, MD, MD Anderson Cancer Center, Houston, TX. Zhanni Lu, MPH, MD Anderson Cancer Center, Houston, TX. Janet Williams, MPH, UT, MD Anderson Cancer Center, Houston, TX. Barriers and Facilitators to the Conduct of Eduardo Bruera, MD FAAHPM, MD Anderson Cancer Timely Interdisciplinary Family Meetings in Center, Houston, TX. the ICU: Perspectives from a Diverse Sample Objectives of ICU Clinicians (FR441C) Understand Decisional Control Preferences Jennifer Seaman, PhD RN, University of Pittsburgh, (DCP) in Palliative care patients who prefer fam- School of Medicine, Pittsburgh, PA. Robert Arnold, ily make decisions regards to care on their behalf. MD FAAHPM, University of Pittsburgh, Pittsburgh, Describe frequency and factors associated family PA. Kimberly Rak, PhD MPH, University of Pittsburgh, deferred passive DCP. Pittsburgh, PA. Marci Nilsen, PhD RN, University of Original Research Background. Communication Pittsburgh, School of Nursing, Pittsburgh, PA. Aman- regards to decisional control preferences (DCP) da Argenas, BA, University of Pittsburgh, Pittsburgh, is critical for effective palliative care (PC). There PA. Anne-Marie Shields, MSN RN, University of Pitts- Vol. 53 No. 2 February 2017 Schedule With Abstracts 371

burgh, Imperial, PA. Douglas White, MD, University of merit development and testing to address this gap in Pittsburgh, Pittsburgh, PA. clinical care. Objectives List 3 clinician-level barriers to the conduct of interdisciplinary family meetings (IDFMs) in the Psychometric Properties of the Comfort with ICU. Communication in Palliative and End-of- List 3 unit-level barriers to the conduct of inter- Life Care (C-COPE) Instrument (FR441D) disciplinary family meetings (IDFMs) in the ICU. Mary Isaacson, PhD RN CHPN, South Dakota State Original Research Background. Leaders in critical University, Brookings, SD. Patricia Da Rosa, MSc, care and palliative care (PC) have called for inte- South Dakota State University, Brookings, SD. Mary grating PC practices into ICU care, since most Minton, PhD RN CNS CHPN, South Dakota State Uni- ICU patients and families have unmet PC needs. versity, Brookings, SD. Shana Harming, BS, South Timely interdisciplinary family meetings (IDFMs) Dakota State University, Brookings, SD. address core PC needs by providing a setting where Objectives family members can receive clinical information Describe the strategies used to develop the Com- and emotional support; engage in elicitation of pa- fort with Palliative and End-of-Life Care (C- tient values; and thoughtfully deliberate about COPE) instrument. treatment choices. However, fewer than 20% of Discuss the results and the decisions made ICU patients have an IDFM within 5 days of ICU because of the results from the psychometric anal- admission. ysis of the C-COPE. Research Objectives. Guided by an implementation Original Research Background. Caring for pa- science framework, the purpose of this study is to un- tients and families experiencing life-limiting illness derstand clinician-, unit- and institutional-level bar- requires that healthcare professionals are comfort- riers and facilitators to holding timely IDFMs and to able in initiating crucial palliative and end-of-life elicit clinicians’ ideas for future interventions. (EOL) care discussions. Nurses spend the most Methods. We conducted in-depth, semi-structured time with patients and must feel at ease discussing telephone interviews with ICU clinicians to elicit palliative and EOL care options with patients and perceived barriers and facilitators to the conduct of families. No validated instrument exists which as- timely IDFMs. Using the AHA database we purposively sesses nurse comfort specific to palliative and EOL sampled doctors, nurses and care managers in a range care communication. of practice settings (e.g., geographic region, size, aca- Research Objectives. The aim of this study is to demic affiliation, and intensivist involvement). We per- report the psychometric properties of the Comfort formed constant comparative content analysis to with Communication in Palliative and End-of-Life generate a matrix of themes, ceasing enrollment Care (C-COPE) instrument among rural and urban with thematic saturation. nurses. Results. We interviewed 13 clinicians. All value Methods. The authors designed a 28-item survey IDFMs for their ability to achieve clear communica- (C-COPE) to assess nurse comfort with palliative tion among and between clinicians and family mem- and EOL communication. Four experts evaluated bers. Clinician-level barriers include: discomfort with content validity prior to survey delivery. Using an on- end-of-life conversations; perception that attending line format, the survey was distributed to a conve- IDFMs is not a nursing priority; and belief that nience sample of rural and urban nurses (N¼271). IDFMs are time consuming. Unit-level barriers To assess test-retest reliability, the questionnaire include: absence of unit-based protocols for IDFMs; was administered twice, two weeks apart and meeting occurrence being dependent upon individ- computed with the Wilcoxon signed-rank test. Inter- ual physicians; and holding meetings only when a de- nal consistency was measured via Cronbach’s alpha. cision is needed. Clinicians endorsed preemptive Factor analysis included principal axis factoring, scheduling upon admission and buy-in at all levels parallel analysis, and oblique rotation (direct obli- dadministrative, physician, nursing to promote min) and was conducted on N¼250 complete C- timely IDFMs. COPE surveys. Conclusion. IDFMs are valued, but barriers may Results. The overall content validity index was accept- impede their routine conduct. Participants describe able at 0.98. Median differences between tests were promising unit- and institution-level intervention com- not significantly different. The four factors extracted ponents to overcome barriers. from the oblique factor analysis had an accumulative Implications for research, policy or pract- variance of 63%: (1) Patient Symptomatology, (2) ice. Interventions that incorporate these components Values, (3) Team Communication, and (4) Decision- 372 Schedule With Abstracts Vol. 53 No. 2 February 2017

making. The Cronbach’s alpha coefficient for the total This workshop will demonstrate the process of score was 0.91 and for factors 1 through 4 was 0.85, designing a complimentary needs assessment/curricu- 0.87, 0.88, and 0.87, respectively. lum pair, and present needs assessment, curriculum Conclusion. The C-COPE demonstrated satisfactory development and needs reassessment as a continuous content validity, internal consistency, and stability in cycle, similar to that of continuous quality improve- measuring nurse comfort with palliative and EOL ment. Through didactics and small group discussion, communication. a needs assessment instrument and curriculum devel- Implications for research, policy or practice. The oped by the authors will be used to illustrate this pro- four factor structure suggests relevant communication cess. Opportunities will be provided for participants to foci necessary to assess nurse communication compe- share their own experience, and to consider what the tence. Testing of this instrument is recommended in crucial next steps they might initiate to begin a similar a larger more diverse sample. process at their own institution.

3e4pm ‘‘Is This Patient Appropriate for Hospice?’’ Concurrent Sessions Lively Perspectives from the Hospice Liaison, Medical Director, and Executive Vice President (FR451) Stanley Savinese, DO HMDC FAAHPM, Temple Uni- Primary Palliative Care Education: A Case versity Hospital, Hahnemann University, Philadelphia, Study in Needs Assessment and Curricular PA. Jane Feinman, MSN RN, VNA/Hospice of Phila- Development (FR450) delphia, Philadelphia, PA. Linda McIver, MSN RN, Thomas Carroll, MD PhD, University of Rochester, Ro- Hospice of Philadelphia, Philadelphia, PA. chester, NY. Neal Weisbrod, MD, University of Roches- Objectives ter, Rochester, NY. Laura Hogan, MSN RN NP-C Foster a concrete understanding regarding which ACHPN, University of Rochester, Rochester, NY. potential patients are appropriate for admission Timothy Quill, MD FACP FAAHPM, University of Ro- to hospice care by participating in lively discus- chester Medical Center, Rochester, NY. sion with faculty members. Objectives Develop strategies to work through determining Describe the process of designing needs assess- whether or not hospice care can meet the needs ment and survey instruments. of the changing and complex patients they are Describe the process of curriculum development asked to evaluate for admission. for professional learners. Hospice eligibility is no longer straightforward. Hos- Utilize needs assessment to drive curriculum pices are being called upon to care for patients with development and implementation. diseases which do not have a predictable trajectory. Given the ever-worsening shortage of palliative care Patients are living longer and better with chronic ill- clinicians in the United States, it is imperative that nesses, and complex interventions for chronic issues the field continues to focus on educational efforts. If such as heart failure can blur the line between com- successful, education expands the capabilities of fort and aggressive treatment. Interpretation of hos- non-palliative care specialists to provide basic pallia- pice regulations to foster the patients’ best interest tive care services to patients and families who may is challenging. Many pressing issues surround hospice otherwise go without. Educational efforts can take enrollment including establishing timely dispositions any number of forms, from bedside teaching of for hospitalized patients, maintaining a hospice trainees to informal curbside opinions for colleagues census that is able to sustain the necessary resources, to formal curricula. ensuring that the hospice can provide the promised Although there are many possible explanations when interventions, and avoiding undue scrutiny from reg- an educational effort fails, one that should not be ulatory bodies that can disrupt revenue. Determina- overlooked is a major mismatch between self- tion of eligibility is not for the faint of heart. A perceived educational needs and curricular offerings. multidisciplinary approach and open discussion is es- This is frustrating for all involved and leads to lost sential. educational opportunities. It is imperative that before undertaking any educational effort, regardless of setting or method, potential learners’ willingness/ Three Palliative Care Models in Population desire to learn is accurately assessed. Only then can Health Management Systems (FR452) the education effort be tailored appropriately to maxi- Joshua Lakin, MD, Harvard Medical School, Boston, mize the likelihood of success. MA. Catherine Arnold, MSW LICSW, Brigham & Vol. 53 No. 2 February 2017 Schedule With Abstracts 373

Women’s Hospital, Boston, MA. Rachelle Bernacki, Creating a Village and Supporting Culture MD MS FAAHPM, Dana-Farber Cancer Institute, Bos- Change: Facilitating Advance Care Planning ton, MA. Rebecca Cunningham, MD, Brigham & by Teaching Everyone How to Have an Women’s Hospital, Boston, MA. Julia Gallagher, MD, ‘‘Introductory Conversation’’ (FR453) Massachusetts General Hospital, Boston, MA. Martha Gordon Wood, MD FAAHPM, Northwestern Univer- Quigley, MS GNP-BC ACHPN, Massachusetts General sity, Chicago, IL. Eytan Szmuilowicz, MD, North- Hospital, Boston, MA. Jan Lamey, MS, Brigham & western University, Chicago, IL. Katie Clepp, MA Women’s Physicians Organization, Boston, MA. Arjun MEd, Northwestern University, Chicago, IL. Rangarajan, MPH MBBS, Brigham & Women’s Physi- Objectives cians Organization, Boston, MA. Describe a model for the ‘‘Introductory Conversa- Objectives tion’’ by which any staff member can introduce Describe the state of the science of population advance care planning and/or respond when a health management and the potential intersec- patient or family member expresses a concern tions with palliative care. or need. Discuss the rationale, design and target popula- Practice an ‘‘Introductory Conversation’’. tions for 3 programs designed to deliver earlier List one way this model could be applied to cata- palliative care to specific subpopulations of pa- lyze culture change at the participant’s home tients within a PHM system. institution. Describe opportunities and challenges in imple- Although the benefits of advance care planning have menting palliative care interventions across the been repeatedly demonstrated in the literature, spectrum of patient illness in population health many patients and providers still do not participate management programs. in these discussions and, even if they do, many sys- Population Health Management (PHM) is an tems are not set up to consistently and effectively emerging model of care that has developed in honor these care plans. Calls for culture change response to the transition from fee-for-service to abound but there is no clear method to achieve value-based, shared-risk care. PHM aims to systemati- this aim. cally and proactively address the unmet or under- The Preference-Aligned Communication and Treat- met needs of a targeted group of patients, such as pre- ment (PACT) Project is a multi-site, multi-year ventative aspects of care, psychosocial determinants of advance care planning initiative currently underway health, and chronic care needs. PHM algorithms often in Illinois. To help achieve culture change, the project identify patients with the highest health care costs has created an innovative approach in which everyone (‘‘high utilizers’’), many of whom have significant un- involved in the care of the patient (doctor, nurse, met palliative care needs. These needs include earlier nursing assistant, physical/occupational/respiratory advance care planning, symptom management and therapist etc.) receives training so they understand psychosocial and spiritual support. the importance of advance care planning and can The Institute of Medicine in its recent publication, bring it up if they sense a need or respond appropri- Dying in America, calls for ongoing integration of social ately if the patient brings it up. This conversation, and medical services in meeting palliative care needs based on a novel framework called ‘‘SONAR,’’ is a for all patients; a call that mirrors many of the core ac- cyclical process in which the clinician is continuously tivities of PHM. Additionally, a growing evidence base sending and receiving messages by observing, naming suggests that palliative care, when delivered along with emotions, asking questions, and acknowledging what usual medical care, improves the value of the care the patient has shared. delivered to the patient, increasing quality while This session will describe this initiative and model in decreasing costs: an outcome that aligns with the more detail and share how it is being implemented PHM model of care. Given these reasons, PHM sys- across 10 hospitals and 20 post-acute care sites in Il- tems and palliative care programs would appear to linois with plans to expand further in subsequent co- be natural collaborators in developing innovative, pa- horts. Participants will witness and be able to discuss tient-centered models of care. In this session, we a sample ‘‘Introductory Conversation’’ and will have explore the role of palliative care programs in PHM the opportunity to practice the conversation them- by presenting three programs as examples, using di- selves. The session will close with a discussion of dactic presentation, cases, and facilitated group work how participants may be able to use these tech- to derive practical implementation tips for partici- niques to catalyze culture change at their home pants to take back to their home institutions. institution. 374 Schedule With Abstracts Vol. 53 No. 2 February 2017

Together We Can Go Farther: Using outcomes (e.g. daily symptom scores). Members of Palliative Care Registries and the collaboratives use standardized data to drive multi- Collaboratives to Drive Quality site QI initiatives. These growing networks allow Improvement (FR454) benchmarking and identification of best practices to Katherine Ast, MSW LCSW, American Academy of promote greater gains in QI than any service could Hospice and Palliative Medicine, Chicago, IL. Chris- make alone. tine Ritchie, MD FAAHPM, University of California The National Palliative Care RegistryÔ is a national San Francisco, San Francisco, CA. Steven Pantilat, annual survey focusing on composition and opera- MD FAAHPM, University of California San Francisco, tions of palliative care programs. The goal of the Reg- San Francisco, CA. Kara Bischoff, MD, University of istry is to: assist palliative care programs in tracking California San Francisco, San Francisco, CA. Arif Ka- their development year-to-year; and promote stan- mal, MD MBA MHS FAAHPM, Duke Cancer Institute, dardization and improve the quality of palliative Durham, NC. Tamara Dumanovsky, PhD, Center to care. The Registry provides actionable information Advance Palliative Care, New York, NY. Maggie Rogers, that programs can use to secure, expand and retain re- MPH, Center to Advance Palliative Care, New York, sources for delivery of high-quality palliative care. Data NY. from the registry can also support the establishment of new palliative care programs where none exists. Objectives In this session, attendees will learn about these initia- Discuss the current landscape of quality measure- tives and how together they support the improvement ment and why it’s important for program develop- and expansion of palliative care programs in comple- ment, quality improvement (QI), monitoring the mentary ways. Data from each contribute to our un- field, and reporting for quality and payment. derstanding of practice and quality and addresses Describe an overarching palliative care quality essential issues regarding reporting and payment. At- strategy that can be used to improve the quality tendees will learn how these efforts fit into an over- of care at attendees’ local institutions. arching palliative care quality strategy. Describe how our separate quality strategies meet these needs and how they will collaborate into one overarching quality initiative for our field co- ordinated by AAHPM. Truth-Telling in Pediatric Palliative Care: Describe the advantages of participating in data Challenges and Opportunities (FR455) collection collaboratives such as the Palliative Tracy Hills, DO, Vanderbilt Children’s Hospital, Nash- Care Quality Network (PCQN), Global Palliative ville, TN. Adam Marks, MD, University of Michigan, Care Quality Alliance (GPCQA), and the National Ann Arbor, MI. Christian Vercler, MD MA, University Palliative Care RegistryÔ. of Michigan, Ann Arbor, MI. Describe how to use comparative data to evaluate Objectives your own palliative care program, improve your Review the existing data regarding practices and quality of care, and enable the Measuring What Mat- perceptions of truth-telling for children faced ters initiative, The Joint Commission quality report- with a terminal disease. ing, and other national quality reporting programs. Understand the ethical principles as they pertain As palliative care programs face increasing pressure to to truth-telling in pediatric palliative care. demonstrate their quality in order to advocate for sup- Review effective communication techniques for port and expansion and to be paid by insurers, stan- truth-telling and for navigating potential sources dardization in collection and reporting of quality of conflict around truth-telling. data is increasingly important to allow for bench- Truth-telling, or the act of disclosing factual informa- marking and reporting. Three initiatives address these tion to patients and/or their families, is common prac- needs: the Palliative Care Quality Network (PCQN), tice in western societies and is largely related to an the Global Palliative Care Quality Alliance (GPCQA), emphasis on respect for patient autonomy. In pediat- and the National Palliative Care RegistryÔ. This ses- rics, the relationship between the family and physician sion provides an overview of these initiatives, describes is often complex with multiple facets contributing to their collaboration, and discusses how they are how and what information is communicated. The fam- together advancing quality improvement and posi- ily often becomes the gate keeper to what information tioning our field for reporting and payment. their child knows. This dynamic becomes more com- The PCQN and GPCQA are quality improvement (QI) plex when the child transitions to adolescence and collaboratives that support teams to collect prospec- young adulthood, where the patient’s autonomy tive, standardized data on key care processes (e.g. comes in conflict with that of the parents. In addition, advance care planning activities) and patient-level truth-telling is not a globally accepted practice with Vol. 53 No. 2 February 2017 Schedule With Abstracts 375

many factors, including culture, religion, personal be- studies, and group discussion, we formulate potential liefs, and family dynamics playing a role. This can lead treatment approaches, including psychotherapy, medi- to conflicts between the family and the health care cation, and psychosocial interventions from the inter- team who hold to the societal norms of truth telling disciplinary team for various manifestations of the and respect for individual autonomy. depressive spectrum. We will begin this session with a case report of a young adult with metastatic cancer being treated in a pediat- The Emerging Business Case for Community- ric institution for whom truth-telling was resisted by Based Palliative Care (FR457) the parents. We will then review the literature J Brian Cassel, PhD, Virginia Commonwealth Univer- regarding truth-telling and disclosing prognosis to sity, Richmond, VA. Kathleen Kerr, BA, Kerr Health- children and young adults, followed by an ethical anal- care Analytics, Mill Valley, CA. ysis of truth-telling and how it applies to our case. Finally, we will end with a discussion of strategies Objectives health care providers can use to assess the appropri- Understand the impact of community-based PC ateness of truth-telling in individual cases, as well as on costs and revenues. methods for talking with children and young adults Apply the principles of the business case to get- about death. ting resources and support needed for commu- nity-based PC. Access tools and resources to help quantify and The Depressive Spectrum make a compelling business case for community- (FR456) based PC proposals. Erin Zahradnik, MD, Icahn School of Medicine at The fact that inpatient palliative care reduces hospital Mount Sinai, New York, NY. Priya Krishnasamy, MD, costs is well-established, with much research Mount Sinai Hospital, New York, NY. Jodi Smith, describing how and why. The business case for inpa- LMSW, Mount Sinai Beth Israel, New York, NY. tient palliative care is clear for hospitals: reducing Objectives costs in the context of case-rate payments for hospital Distinguish between clinical depression, demoral- care. In contrast, the business case for community- ization, and grief reactions. based palliative care is just emerging. There has Explain what demoralization is and how it mani- been less research demonstrating the impact on utili- fests in serious illness. zation and costs. There is also a more complex set of Describe grief reactions and how they differ from considerations regarding whose costs and revenues demoralization. would be affected by providing better care for patients Depressive symptoms are common in palliative care with advanced, life-limiting diseases, and doing so patients, though the etiology is often complex. Given earlier in the disease course than inpatient PC and the heterogeneity of depression, it can be useful to hospice do currently. characterize it as a spectrum. Depressive syndromes In this session, we will first review the published occur along this spectrum, only part of which is repre- research on the impact of home-based and clinic- sented by diagnosable clinical depression. Distinguish- based palliative care programs, especially in terms of ing these different syndromes can be difficult, which the impact on emergency visits, hospitalizations, and complicates treatment for patients, thus impacting overall healthcare costs. This will answer questions their quality of life. about whose costs (hospitals? payers? both?) are Demoralization, a psychological reaction to diffi- reduced when community-based PC makes hospitali- culty coping with serious illness, can initially appear zations unnecessary. Second, we will review the shift- to be major depressive disorder. Similarly, grief reac- ing landscape of healthcare reimbursement, tions, not only in response to impending loss of life, pointing out scenarios such as Accountable Care Or- but also to loss of function, physical abilities, and ganizations where there is greater interest in other changes common in serious illnesses, can increasing quality of care and in reducing costs. We manifest with depressive symptoms. Distinguishing then put the two together, describing how successful these phenomena is important in order to effec- community-based PC programs have found sponsors tively treat these symptoms in patients at the end and resources where the clinical (patient-centered) of life. and financial (business-centered) outcomes are In this concurrent session, we utilize our backgrounds aligned. in psychiatry, palliative medicine, and social work to Case studies of prominent home-based and clinic- explain the similarities and differences between major based palliative care programs will be described, as depressive disorder, adjustment disorders, grief reac- will tools and resources provided by the California tions, and demoralization. Through lecture, case HealthCare Foundation focused on making the case 376 Schedule With Abstracts Vol. 53 No. 2 February 2017

for community-based palliative care. Audience partici- decision making. By the conclusion of the session, it pation will include discussion of instances where such is anticipated that participants will be better able to arguments for community-based palliative care have efficiently incorporate evidence-based medicine into worked, and where they have not. their clinical practice.

The Intersection of Research and Clinical Practice: The Art and Science of Reading a Caring for Patients Whose Decision-Makers Paper (FR458) Have Questionable Capacity: Ethical and Donna Zhukovsky, MD FACP FAAHPM, MD Anderson Clinical Concerns (FR459) Cancer Center, Houston, TX. David Hui, MD MS Jeffrey Berger, MD FACP, Winthrop Hospital, Mineola, MSC, MD Anderson Cancer Center, Houston, TX. Ro- NY. Joel Frader, MD FAAP, Lurie Children’s Hospital, nit Elk, PhD, University of South Carolina, Columbia, Chicago, IL. Bridget Sumser, LMSW ACHP-SW, Uni- SC. versity of California San Francisco Medical Center, Objectives San Francisco, CA. Review the process of searching for relevant arti- Objectives cles to the clinical question of interest. Describe the phenomenon of decision makers Demonstrate an overview of a systematic process with questionable capacity and its ethical implica- for critically evaluating quality of quantitative tions in adult care. manuscripts reporting clinical research. Explore the ethical implications and obligations Provide a paradigm to evaluate applicability of associated with care of pediatric patients whose research results to hospice and palliative care clin- decision makers may lack adequate capacity to ical practice. make needed decisions. With the recent explosion of technology and social Discuss strategies for managing situations involving media platforms, busy clinicians are continuously decision makers suspected of being impaired. bombarded with data. Not all data are worthy of the Palliative care clinicians commonly face high complexity same attention or have implications for the practice and stressful decision making. Decisions by surrogates of hospice and palliative medicine. Using a journal occur for 25%-30% of hospitalized adults, and in pediat- club format, the presenters, a palliative care tenured rics parents usually serve as legal surrogates. The ethical physician scientist, an academic palliative care clini- and legal authority for such decisions is well established. cian and a PhD researcher and former American Can- However, not well described are problems with decision- cer Society study section program director, will discuss makers suspected of impaired decisional capacity. These the art of scientific reading. We will start by discussing individuals may have well-recognized or undiagnosed how to identify relevant studies by formulating the psychiatric disorders, impairment from substance abuse, appropriate clinical question. As busy clinicians and or cognitive disorders such as dementias. Unfortunately, researchers often do not have time to read beyond clinicians caring for the index patient have no standing the abstract, we will then illustrate the importance of to formally assess surrogates, to substantiate suspicions reading beyond the abstract, as a thorough review of that the decision maker are impaired, or to direct the manuscript often provides important insights, them to health care services. In some circumstances, and may sometimes lead the reader to reach a e.g., suspected abuse or neglect of minors or elders, clini- different conclusion, highlighting the need to ‘‘dig cians may have options for reporting surrogates to public deeper.’’ Next, we will demonstrate an efficient way authorities. In all cases, clinicians may have ethical obli- to screen published research in order to decide if gations to intervene on behalf of dependent, vulnerable the work is of sufficient quality to merit further review patients. Clinicians may also have ethical duties to the and to determine if study results are valid and clini- impaired decision maker, even without a clinician-pa- cally significant. Moving on we will apply the evi- tient relationship. How ought clinicians manage these dence-based medicine framework to critically circumstances? In this presentation we discuss these appraise some recently published research articles, challenges from the perspectives of a pediatric palliative answering 3 key questions: ‘‘Are the results valid?’’ care physician, an adult palliative care physician, and a ‘‘What are the results?’’ ‘‘Are the results applicable to palliative care social worker. my practice?’’ Emphasis will be placed on the process of assessing the methods (e.g. sample size, study dates, Neither Hastening nor Prolonging Death: eligibility criteria, nature of control group, outcome Hospice in a State with Legalized Physician- measures). Finally, the panelists will discuss the pro- Assisted Death (FR460) cess of knowledge translation and how to make sense Krista Harrison, PhD, University of California San of the rapidly evolving literature to inform clinical Francisco, San Francisco, CA. Margaret Bourne, MD Vol. 53 No. 2 February 2017 Schedule With Abstracts 377

HMDC, Hospice by the Bay, San Francisco, CA. Court- legalization. Ms. Koehler, hospice Director of Clinical ney Campbell, PhD, Oregon State University, Corval- Services, will describe the impact of legalized PAD on lis, OR. Laura Petrillo, MD, Veterans Affairs Medical hospice interdisciplinary team dynamics. Center, San Francisco, CA. Laura Koehler, LCSW ACHP-SW, Hospice by the Bay, San Francisco, CA. Objectives Paper Sessions After attending this session, participants will be able to analyze a relevant case regarding consider- ations of hospice organizations developing pol- What Is In The Palliative Care Syringe? Key icies to respond to legalized physician-assisted Activities of an Outpatient Palliative Care death. Team at an Academic Cancer Center After attending this session, participants will be (FR461A) able to explain how hospices in Oregon and Kara Bischoff, MD, University of California San Fran- Washington responded to the legalization of cisco, San Francisco, CA. Eleanor Yang, BA, University physician-assisted death in their states. of California San Francisco, San Francisco, CA. Gayle After attending this session, participants will be Kojimoto, BA, University of California San Francisco, able to list the specific challenges of legalized San Francisco, CA. Nancy Shepard Lopez, MS RN physician-assisted death in California. ACHPN, University of California San Francisco, San The End of Life Option Act, which gives patients with Francisco, CA. Brook Calton, MD, University of Cali- a terminal illness the ability to request medication to fornia San Francisco, San Francisco, CA. Bruce (bj) end their lives, went into effect in California in June Miller, MD, University of California, San Francisco & 2016. This makes California the fifth state to legalize Zen Hospice Project, San Francisco, CA. Sarah physician-assisted death (PAD), though legislation is Holland, RN, University of California San Francisco under consideration in seventeen more. After PAD be- Medical Center, San Francisco, CA. Michael Rabow, comes legalized, health care organizations must MD, University of California San Francisco Medical develop new practices to respond to requests from pa- Center, San Francisco, CA. tients. Since laws define the steps a physician must Objectives take to write a prescription, organizational responses Understand the key functions of an outpatient typically focus on the early part of the process of re- palliative care team. questing hastened death. However, evidence from Or- Understand areas for improvement for an outpa- egon and Washington suggests the vast majority of tient palliative care team. terminally ill individuals who request PAD are hospice Original Research Background. The field of outpa- patients. Hospices must consider issues such as manag- tient palliative care (PC) is growing rapidly and there ing communication with family, effects on interdisci- is not yet consensus about key elements of this work. plinary team members, and issues around ingestion, Research Objectives. Describe the activities of an while accounting for a hospice philosophy that clini- outpatient PC team at an academic cancer center. cians will neither hasten death nor prolong life. Methods. Providers at the outpatient PC clinic (the For clinicians and leaders in states that have recently ‘‘Symptom Management Service’’) at University of Cal- legalized or may soon legalize physician assisted death, ifornia, San Francisco’s comprehensive cancer center this concurrent session highlights the PAD-related pol- completed a checklist following each visit between icies and practices of hospice organizations in Ore- 03/23/2015 and 06/14/2016 to document topics gon, Washington, and California. Dr. Harrison, a covered during the visit. health policy researcher, will review the current Results. Data was analyzed from 1288 visits during the nationwide policy context for PAD and engage the study period. Initial PC visits (n¼333) most commonly audience in a case discussion. Dr. Campbell, an expert focused on symptom management (92%), an introduc- in hospice ethics, will describe ethical dilemmas tion to PC (69%), support for family/caregivers (47%), encountered by hospices in Oregon and Washington communication with other clinicians (38%), and responding to legalized PAD. Dr. Petrillo, palliative assessment of patients’ understanding of their medical care physician and organizer of the California End treatments (36%). Follow-up visits (n¼ 909) commonly of Life Option Act Response Conference, will report focused on symptom management (93%) and less on the challenges of legalized PAD in such a large often included support for family/caregivers (27%), and diverse state. Dr. Bourne, hospice Chief Medical communication with other clinicians (19%), assess- Officer, will share the experiences of a consortium of ment of patients’ understanding of their medical treat- Bay Area hospices eight months after California ments (14%), and support for decision-making (12%). 378 Schedule With Abstracts Vol. 53 No. 2 February 2017

From analysis of data from the 89 patients who initi- with evidence of recent decline in health state’’. A ated their care and died during the study period, we comprehensive assessment was done which included found that initial PC visits occurred an average of elements of a palliative care consult and a comprehen- 135 days prior to death. Most patients received care sive geriatric assessment. focused on symptom management (96%), an intro- Results. From January 1st to June 30th, 2016, eighty- duction to PC (70%), support for family/caregivers four patients were seen. The mean age was 85 years (67%), and communication with other clinicians with evidence of serious illness in 68%, functional (55%). However, most patients did not have the impairment (dependence in two or more ADLs) in following topics addressed at any point during their 87%, and cognitive impairment in 73% at baseline. ambulatory PC: preferred place of death (93%), dis- During hospital stay, 56% had evidence of delirium, cussion of hospice (85%), completion of an advance 46% had physical symptom burden, 35% had psy- directive or Physician Orders for Life-Sustaining Treat- cho-social distress. 60% had two or more hospital or ment form (83%), support for decision making ED visits in the prior six months and 40% had been re- (80%), and designation of a healthcare proxy (73%). admitted within 30 days. 7% passed away during hospi- Conclusion. Key functions of our ambulatory PC team tal stay and 10% were discharged with hospice. are symptom management, support, and care coordi- Conclusion. We may be able to identify this cohort nation. However, many elements of advance care plan- early by using markers of frailty (dependence of ADLs, ning are not commonly provided during clinic visits. cognitive impairment) and utilization (ED visits). Implications for research, policy or practice. Our Implications for research, policy or practice. In data help describe outpatient PC and highlight oppor- the environment of value-based purchasing, tunities for improvement. health systems and policymakers are looking at identi- fying complex patient populations at risk of poor out- Designing a Value-Based Care Delivery comes and high utilization. Also, patient-centric Model for Complex Older Adults Based on outcomes (function, symptom and communication) Geriatric and Palliative Care Principles in the value equation may increase likelihood of impact. (FR461B) Ankur Bharija, MD, Stanford University Medicine, Palo Alto, CA. Astrid Block, RN CNS, Stanford Health- Projecting the Impact of Implementing care, Palo Alto, CA. Palliative Care for Older Adults: What Does Objectives the Evidence Support? (FR461C) Identify patient characteristics in the older adult Adam Singer, PhD, Rand Corporation, Santa Monica, population, which have a high likelihood of asso- CA. Duncan Ermini Leaf, PhD, University of Southern ciation with poor patient outcomes and high California, Los Angeles, CA. Manali Patel, MD, Stan- health care utilization. ford University, Stanford, CA. Karl Lorenz, MD Identify triggers for predicting a decline in the ag- MSHS, Stanford University, VA Palo Alto, Palo Alto, ing and serious illness trajectories so geriatric and CA. Daniella Meeker, PhD, University of Southern Cal- palliative care principles can be integrated up- ifornia, Los Angeles, CA. stream in the care continuum. Objectives Original Research Background. Complex older Learn about the potential future impacts of effec- adult population is a segment we often refer to as tive palliative health services interventions. ‘high utilizers’ and most ‘at-risk’ of sub-optimal care. Learn about the applications of a powerful simu- This segment may benefit most from upstream inte- lating model for projecting changes over time in gration of geriatric and palliative care principles in end-of-life populations. the care plan. Our biggest challenge may be early Original Research Background. A 2014 Institute of identification of this cohort, at the onset of decline Medicine report concluded that broad improvements in health status. in end-of-life care are within reach. However, many Research Objectives. Identify patient characteristics currently available evidence-based palliative health ser- and triggers in the older adult population, which have vices interventions have not been implemented on a a high likelihood of association with poor patient out- large scale. comes and high health care utilization. Research Objectives. Informed by our recent Methods. As part of assessing senior care needs at systematic review of 124 RCTs of palliative health Stanford Hospital, we piloted a new consult service services interventions from 2001 to 2015, we projected ‘‘ACE e Acute Care for Elders’’. We created a simple changes from 2016 to 2040 in health care costs, inpatient consult trigger e ‘‘Age 75 years and older quality of life, and mortality resulting from the Vol. 53 No. 2 February 2017 Schedule With Abstracts 379

implementation of a palliative care team (PCT) for unmet need for palliative care in US hospitals remains cancer patients and palliative case management largely unknown. (CM) for CHF patients. Research Objectives. We conducted a multi-site Methods. The Future Elderly Model is a microsimula- cross-sectional, retrospective point prevalence analysis tion model derived from the Health and Retirement to determine the size and characteristics of the popu- Study and Medicare data that projects the health sta- lation of inpatients at 33 US hospitals who were appro- tus, quality of life, and economic outcomes of the priate for palliative care referral, as well as the US adults over age 50. We informed the model with percentage of these patients who were referred for parameters from RCTs identified in our systematic and/or received palliative care services. review. Methods. Patients appropriate for palliative care Results. From 2016 to 2040 in the absence of any referral were defined as adult ($18 years) patients intervention, projections show increases in life expec- with any diagnosis of a poor-prognosis cancer, New tancy and societal health care costs, and worsening York Heart Association Class IV congestive heart fail- pain, depression, and ADL difficulties. The PCT inter- ure, or oxygen-dependent chronic obstructive pulmo- vention directly reduced depression in cancer patients nary disease who had inpatient status in one of 33 by 75.6% (sensitivity analysis, 70.6%-80.4%) and the hospitals on May 13, 2014. Qualitative assessment PCM intervention directly reduced average ADL diffi- involved interviews of palliative care team members culties in CHF patients by 33.7% (19.4%, 37.1%). and non-palliative care frontline providers. Both interventions reduced per capita societal health Results. Nearly 19% of inpatients on the point preva- care costs, increased QALYs, and reduced mortality. lence day were deemed appropriate for palliative care The PCT intervention reduced societal health care referral. Of these, approximately 39% received a palli- costs by $103 billion ($95.4 billion, $109 billion). ative care referral or services. Delivery of palliative care Conclusion. In the absence of changes in current services to these patients varied widely among partici- practices, cost and quality of life outcomes at the pating hospitals, ranging from approximately 12% to end of life in cancer and CHF patients are projected more than 90%. Factors influencing differences in to worsen over time. Palliative health services interven- referral practices included non-standardized percep- tions have the potential to positively impact these out- tions of referral criteria and variation in palliative comes over time. care service structures. Implications for research, policy or prac- Conclusion. This is the first multi-site study designed tice. Policymakers and payers should consider invest- to estimate the prevalence of hospitalized patients ing in and implementing evidence-based palliative appropriate for palliative care referral in US hospitals. approaches, as they may reduce costs and have an The findings demonstrate the need to expand the array of positive quality of life impacts in cancer and availability of palliative care services, including pri- CHF. mary palliative care delivered by frontline providers. Implications for research, policy or practice. The study provides useful information to guide providers, Gaps in the Use of Palliative Care in US administrators, researchers, and policy experts in Hospitals (FR461D) planning for optimal provision of palliative care ser- Jocelyn Vaughn, MA, Vizient, Chicago, IL. Marilyn Sze- vices to those in need. kendi, PhD MSN RN, UHC, Chicago, IL. Objectives 4:30e5:30 pm Describe the prevalence of patients in US aca- demic medical centers who are appropriate for Concurrent Sessions palliative care referral. Identify the varying levels of palliative care refer- rals, consultations, and services among the hospi- Words Matter: Improving the Palliative tals that participated in the study. Care Message (FR470) Discuss the individual, programmatic, and organi- Lisa Morgan, BA, Center to Advance Palliative Care, zational characteristics that result in differing New York, NY. Diane Meier, MD FACP FAAHPM, levels of palliative care coverage for patients Icahn School of Medicine at Mount Sinai, New York, appropriate for palliative care referral. NY. Original Research Background. The approach to Objectives care for individuals with serious, life-threatening Identify the top evidence-based messages that illness seems to be shifting. However, the extent of best define palliative care. 380 Schedule With Abstracts Vol. 53 No. 2 February 2017

Illustrate the visual messages that patients and Apply best practice to physician documentation families respond to most. of the CTI and relatedness. Identify three strategies that present ideal posi- Discuss how to develop hospice coverage guide- tioning opportunities. lines and a hospice formulary. The field continues to use confusing language and Presentation 1 of 2: New and ever changing regula- convey mixed messages. Words matter. Primary, gener- tions for hospices continue to challenge us to improve alist, specialist, advanced, serious, supportive. How our documentation, streamline our processes, and meaningful are these terms to our key audiencesdes- determine relatedness and coverage of diagnoses pecially in diverse settings? and medications. Join us to understand best practice Palliative care has a positioning problem. It is already for documenting CTIs as well as explore common is- an established medical subspecialty that has been sues around determining diagnostic relatedness and shown to improve the quality of care patients receive. hospice provision of medications. This session will Even so, research conducted in spring 2011 found include an up-to-date report on current and proposed three in four Americans (78%) knew nothing about regulations; the development and structure of a palliative care. Physicians also often do not refer pa- persuasive CTI; and tools to help your program to tients who could benefit from palliative care. determine relatedness of diagnoses and coverage of Improving awareness of, and demand for, palliative medications. care is prerequisite to increased access and urgently needed policy changes in payment, accreditation, But the Parents Wanted Us to ‘‘Do regulation and training. Therefore, in order to make Everything’’: Using Values Guided Decision palliative care compelling and relevant to patients Support in Pediatric ICUs (FR472) and families, providers, payers and policymakers, Kenneth Pituch, MD, University of Michigan, Ann Ar- there is an urgent need to educate all Americans. bor, MI. Tessie October, MD, Children’s National Only by making palliative care meaningful to people Health Systems, Washington, DC. Kathleen Meert, will the palliative care field be successful in engaging MD, Children’s Hospital of Michigan, Detroit, MI. and reaching Americans in need. Maureen Giacomazza, MA RN, C.S. Mott Children’s So how do you make palliative care compelling and Hospital, University of Michigan, Ann Arbor, MI. top-of-mind when the vast majority of Americans D’Anna Saul, MD, University of Michigan Hospitals, know nothing about it? How do you reposition it Ann Arbor, MI. Patricia Keefer, MD, University of from end-of-life care to quality-of-life care, positioning Michigan, Ann Arbor, MI. Tracy Hills, DO, Vanderbilt its role in relieving suffering for people of any age and Children’s Hospital, Nashville, TN. at any stage in a serious illness? And how do you make Objectives patients and caregivers aware of it and know to ask for Identify language used in framing an ICU deci- it? These are the challenges facing the field of pallia- sion using the ‘‘needs frame.’’ tive care as a whole. Improving our ability to get and stay on message as a Identify language used in framing an ICU deci- sion in the ‘‘parental autonomy frame.’’ field is prerequisite to our success. Through a didactic Demonstrate language that elicits values and presentation, introduction to new market research and builds trust. interactive Q&A, we will illustrate what ‘‘staying on mes- Pediatric staff working in intensive care units (ICU’s) at sage’’ means and why it is critical for the field’s brand. children’s hospitals are increasingly caring for more chronically critically ill children. Decisions regarding initiation, continuation, escalation, or de-escalation of The Ever-Evolving Role of the Hospice life-prolonging interventions occur frequently in our Medical Director: Quality, Regulations, NICUs, PICUs and Pediatric Cardiac ICUs. Staff often Narratives, Relatedness, and the Hospice perceive that decisions in the best interest of these chil- FormularydPart 1 of 2 (FR471) dren and their families are not always being made. Robert E. Crook, MD FACP, Mount Carmel Hospice Studies of substituted decision making in adult ICU’s and Palliative Care, Columbus, OH. Judi Lund Person, suggests that a guided recommendation, as opposed MPH CHC, National Hospice and Palliative Care Or- to asking surrogates, ‘‘what do you want us to do?’’ leads ganization, Alexandria, VA. Joan K. Harrold, MD to better acceptance of decisions, and perhaps better MPH FACP FAAHPM, Hospice & Community Care, outcomes. We are sharing an approach that is Lancaster, PA. becoming a part of the curriculum for professionals Objectives and trainees at our children’s hospitals. Discuss the current hospice regulatory Objectives environment. After attending this session learners will be able to Vol. 53 No. 2 February 2017 Schedule With Abstracts 381

Identify three ways in which providers frame deci- are shown to both improve quality of life and extend sions regarding life-prolonging interventions: the survival compared to ‘‘usual care’’. needs frame (paternalistic), the parental autonomy The Alameda County Care Alliance (ACCA) Advanced frame (informational, often collaborative) and the Illness Care ProgramÔ (AICP) is a faith-based pro- values-guided decision support frame (collabora- gram designed to address the need for advanced tive and deliberative). illness care in a diverse population of individuals Demonstrate specific language that can elicit served through a consortium of five churches. The values and build trust. AICP leverages key attributes of a diverse faith-led Demonstrate specific language that uses identi- infrastructure that are critical for improving the care fied parental values to present a recommended of the person needing advanced illness care (PNAIC) decision that is shared by the family, but in which and their caregivers in Alameda County, including ac- the burden of the decision is not borne by the cess to health and other community services, trust, parents alone. and spiritual guidance. Demonstrate the ability to listen for acceptance or To our knowledge, the AICP is the first community- the need for further conversation. faith-health system partnership of its kind in the nation initiated by the faith community. The ACCA Methods . Participants will watch two short videos in AICP (1) prepares and empowers faith leaders to pro- which conversations between parents and providers actively counsel their congregants through spiritual is- demonstrate common ways in which decisions are sues related to advanced illness, (2) deploys framed. This will be followed by a review of the litera- community care navigators to closely support PNAIC ture regarding the framing observed in clinical and caregivers in four overarching program domains practice, as well as the ethics literature regarding sur- (physical, psychological, spiritual, and advance care rogate and shared decision making. A third short planning), (3) supports and trains caregivers, and video will model language used to elicit values, estab- (4) integrates its services between hub churches and lish trust and make a values guided recommendation. community resource organizations. The importance of silence, and listening for parental Through discussion, use of case examples, and review feedback will be highlighted. of ACCA AICP pilot data, this workshop will present practical information for forming partnerships with faith-based community led organizations and how to Bridging the Gap Between the Health reach vulnerable populations with advanced illness Delivery Systems, Community Organizations care needs beyond the healthcare delivery system and Faith-Based Communities in Managing through the training and deployment of community Advanced Illness (FR473) care navigators. Cynthia Carter Perrilliat, MPA, Alameda County Care Alliance, Oakland, CA. Valerie Steinmetz, BA, Public Health Institute, Oakland, CA. Home Based Palliative Care: Road to Objectives Success in Non Academic Multispecialty Discuss the formation and operation of the Physician Group (FR474) Alameda County Care Alliance Advanced Illness Lama El Zein, MD, Summit Medical Group, Summit, Care Program. NJ. Betty Lim, MD, Summit Medical Group, Summit, Discuss the training and deployment of faith- NJ. Sarah Masucci, MSW LCSW LCADC, Summit based community care navigators. Health Management, New Providence, NJ. Describe effective ways to provide resources and Objectives information to predominantly African American, Identify the need for different types of home low-income persons needing advanced illness based program in your clinical setting. care and their caregivers. Build a home based palliative care program using Evidence suggests that routine care for individuals your current resources including referral process, with advanced illness does not align treatment plans screening for appropriateness, and the descrip- with patients’ personal goals, and fails to prepare tion of visits and follow up. them for increasingly severe illness. Moreover, there Expandtheroleofpalliativecareintheman- are well-documented racial/ethnic disparities in the agement of complex homebound patients in uptake of advanced illness care including palliative the new era of value-based healthcare delivery care and hospiceddespite the fact that these services models. 382 Schedule With Abstracts Vol. 53 No. 2 February 2017

Palliative care deals with patients with serious illnesses Advanced practice registered nurses (APRNs) have at various stages. With the shift in the healthcare sys- been a key to the expansion of palliative care pro- tem towards a value-based model, it is obvious that grams throughout the country. Unfortunately, a stan- palliative care, which improves quality and decreases dardized pipeline for the support and development cost, will have an important role in caring for patients of new palliative care APRNs does not yet exist. This with chronic illnesses. can leave new palliative care APRNs feeling unsup- Within our practice, we identified multiple areas ported and lost in their new role, and may predispose where palliative care can play a key role. One of these them to the burnout and caregiver fatigue that already areas was the care of patients who are permanently plague our clinical community. New graduate pallia- home bound, patients with debility and severe symp- tive care APRNs and the teams that look to hire this toms post hospital discharge, as well as patients who desired group of clinicians as part of an interdisci- have high palliative care needs and are unable to visit plinary palliative care team need to have in place a our office for consultation. In addition, with the trend framework for professional practice. This session will of merging of outpatient practices, it is becoming use case studies and current literature to describe stra- increasingly difficult for individual clinicians to tegies used to manage expectations for the new grad- perform home visits due to the geographic scattering uate palliative care APRN, map out resources for the of patients. new APRN to support sustainability and longevity in Our palliative care team created a comprehensive the field, and highlight the importance of mentorship home visit program: first we standardized the referral for the new palliative care APRN. We will provide process from all providers by creating a unique framework to assist the APRN in identifying and referral form, second we screened each referral to defining their professional role within the context of identify the specific needs of each patient, and third the palliative care team and larger health system. we categorized patients into three different groups This concurrent session will provide structure for (home based primary care, home based palliative negotiating an employment contract and navigating care and post-discharge care). Each of these three the collaborative physician relationship. Lastly, we groups has specific inclusion criteria and a variety of will identify both clinical resources and career tools services; all provided with an interdisciplinary for the new APN to help make their way through un- approach with focus on quality of life, goal of care charted territory as a palliative care clinician. and patient and family education about disease and medication. Our team worked closely with the group’s ‘‘Life Support’’: A Play about Palliative social services team as well as care managers to identify Care (FR476) and manage this high risk population. Madeline Leong, MD, Johns Hopkins Hospital, Balti- In this session, clinicians will learn how to centralize more, MD. Jay Baruch, MD, Brown University Alpert home visits into one program and how to equip palli- Medical School, Providence, RI. Bonnie Marr, MD, ative care teams for this task by working collaboratively Johns Hopkins Hospital, Ellicott City, MD. with patients’ physicians to avoid unnecessary hospital- Objectives ization and increase quality care for patients in their Identify factors that lead to effective patient-pro- homes. vider communication. Discuss how complex psychosocial issues affect How to Survive as a New Palliative Care patient care. Advanced Practice Registered Nurse (FR475) Reflect on a patient’s journey through illness. Laura E. Tycon, MSN CRNP, University of Pittsburgh For this session, we propose a unique educational Medical Center, Pittsburgh, PA. Margaret C. Root, strategy: combining live theater with a talkback/reflec- MSN RN CPNP CHPPN, University of California San tive exercise. First, we will perform ‘‘Life Support’’, a Francisco, San Francisco, CA. Mary Ersek, PhD RN 90-minute play about palliative care. ‘‘Life Support’’ FPCN, University of Pennsylvania, Philadelphia, PA. tells the story of a complicated patient who transitions Objectives to hospice. After the play, attendees will have an op- Describe strategies used to manage expectations portunity to debrief through a facilitated discussion. for the new graduate palliative care APRN. Goals of this session are: to teach communication Summarize resources available to guide the new skills, promote self-reflection, and highlight complex APRN in cultivating a sustainable professional psychosocial issues. practice. According to the literature, theater can enhance Give examples highlighting the importance of empathy [1], improve case presentation skills [2], mentorship for the new palliative care APRN. and facilitate discussions about ‘‘hot button’’ issues Vol. 53 No. 2 February 2017 Schedule With Abstracts 383

[3]. For example, at AAHPM 2016, Ms. Elaine Magree illnesses, practitioners must make prudent drug ther- presented a play about the AIDS crisis. apy choices. Part of this decision-making process is a The play ‘‘Life Support’’, by Madeline Leong, was careful assessment of the burden-to-benefit ratio, presented at Johns Hopkins Hospital in April 2016. including the financial burden of using each It received substantial press and excellent reviews. medication. Technical requirements are simple. For more in- This concurrent session is a follow-up to previous formation about the play, please contact the primary year’s very popular update on new drugs. For relevant author. drugs approved in 2016, participants will learn about In ‘‘Life Support’’, the characters participate in several the FDA-approved indication for using the medica- goals of care discussions, including a discussion of tion, unapproved uses of the medication (particularly Advance Directives and what it means to receive hos- as it applies to palliative care patients), if it is a pice care. These topics are especially relevant given controlled substance and the schedule (if appro- the known benefit of early palliative care and advance priate), adverse effects, major drug interactions, care planning and the public’s frequent misconcep- dosing, and financial implications of drug procure- tion of these phrases. During the talkback, attendees ment and monitoring if relevant. will discuss the patient-provider communication in Participants will learn what ‘‘NDA Chemical Type’’ the play. Attendees will also have the option to fill (e.g., new molecular entity, formulation, manufac- out a one-page survey about the play. The purpose turer, indication or OTC switch), and ‘‘Review Classi- of the reflective exercise is to act as an interactive fication’’ (priority, or standard review; orphan drug adjunct to the inherent educational value of the play. status) was assigned by the FDA. If available, partici- Yasmina Reza wrote, ‘‘Theater is a mirror.’’ In this pants will also learn the ‘‘new drug comparison rat- session, we hope to use theater as a mirror to demon- ing’’ (1-5, 5 highest in terms of drug importance). strate the nuances of patient-provider communication Most importantly, the participant will learn about and the importance of the words we choose and how the role of the new agent in caring for patients with we speak them. We also hope to create a unique advanced illnesses, and how this medication com- educational experience that contributes to clinician pares with medications already available. Public wellness and burnout prevention. health advisories and drug-related alerts pertinent to end of life care will also be discussed, and their New Drugs and Drug News: The 411 and impact on caring for palliative care patients. Inappro- Implications for Palliative Care (FR477) priate use of medications in hospice or palliative care Mary Lynn McPherson, PharmD MA BCPS CPE, Uni- may result in suboptimal symptom management. This versity of Maryland School of Pharmacy, Baltimore, is a session that every health care professional needs MD. to attend! Objectives List new drugs approved by the FDA in 2016. For each drug the participant will be able to describe AAHPM Review of the USMLE Step the approved indication, unapproved uses of the Examinations (FR478) Robert M. Arnold, MD FAAHPM, University of Pitts- medication, common adverse effects and drug burgh, Pittsburgh, PA. Gary T. Buckholz, MD HMDC interactions. FAAHPM, University of California San Diego, San Die- Describe the burden-to-benefit ratio and the role go, CA. Elise C. Carey, MD FAAHPM, Mayo Clinic Ro- of the medication in caring for patients with chester, Rochester, NY. Jeffrey C. Klick, MD, Children’s advanced illness for each new relevant medication approved in 2016. Healthcare of Atlanta, Atlanta, GA. Laura J. Morrison, MD FAAHPM, Yale-New Haven Hospital, New Haven, Analyze important drug alerts and their relevance CT. Joseph Rotella, MD MA HMDC FAAHPM, Amer- to drug therapies commonly used in hospice and ican Academy of Hospice and Palliative Medicine, Chi- palliative care patients. cago, IL. Solomon Liao, MD FAAHPM, University of Up to 100 new drugs and dosage formulations are California Irvine Medical Center, Orange, CA. Stacie approved every year by the Food and Drug Administra- K. Levine, MD FAAHPM, University of Chicago, Chica- tion (FDA). Some of these are new molecular entities, go, IL. while others are new formulations, new indications, generic drug approvals or labeling revisions. Even if a Objectives drug is a ‘‘new’’ molecular entity, it may not be Describe the current gaps and focus areas of con- ‘‘improved’’ over molecular entities already commer- tent related to hospice and palliative care in the cially available. In caring for patients with advanced USMLE Step examinations. 384 Schedule With Abstracts Vol. 53 No. 2 February 2017

Discuss the opportunities for collaboration with Discuss strategies for implementation of these ini- the NBME to integrate key concepts of HPC tiatives within health care systems. into the USMLE. It is widely accepted that treatment decisions should Apply the implications of the results of the review not be based on medical considerations alone but to their own programs. also on individual patients’ goals, values, and prefer- Most residents will care for people with serious ill- ences for care. It is also widely accepted that for pa- nesses, terminal illnesses, and those near death. tients with serious life-limiting illnesses, advance Nine Hospice and Palliative Medicine Subspecialists directives can be insufficient, and goals of care conver- completed a review of the USMLE Step examinations sations and medical orders are needed to inform med- used for licensing to test the knowledge required to ical decisions. Yet too often goals of care conversations provide this care. The review was planned and devel- are not initiated before a medical crisis occurs, or pa- oped in consultation with the National Board of Med- tient preferences are not captured in a way that is clear ical Examiners (NBME) in early 2016 and completed and easy to locate in the health record. As a result, pa- at the NBME office in Philadelphia, June 15-16, 2016. tients’ wishes may never be known or honored. Ad- At the time of this writing, the data from the review dressing this problem requires significant changes in and the report on the process and outcomes are un- both provider practices and organizational systems. der development. By the time of Annual Assembly, In this session faculty will present and discuss innova- the team will have data to report about the content tive approaches to this problem developed by two ma- related to hospice and palliative care and a summary jor health care systems: Dana-Farber Cancer Institute of gaps in content and initial recommendations for and Veterans Health Administration. These ap- content enhancement to assess progressive student proaches include establishing standards for when level content in the Step examinations. and how goals of care conversations should occur, es- In addition to reviewing the multiple choice ques- tablishing an electronic record template to document tions, the team toured the Communication Skills patient’s goals of care and life-sustaining treatment de- Exam Center where Step 2 exams are completed. cisions, translating patients’ decisions into medical or- The review process provided the opportunity for the ders, training multiple audiences in conducting goals team to explore the strategies currently used to assess of care conversations, and applying proven methods communication skills and to begin to collaborate with of organizational change. Faculty will discuss strategies NBME on future strategies as this is a core competency for implementation of these initiatives within health in Hospice and Palliative Medicine. Representatives care systems including concept development, usability from the review team believe it is important for educa- testing, staff education, pilot testing, implementation, tors to be aware of this review, what was learned, and and evaluation. Faculty will also discuss the experi- be able to discuss opportunities to continue to ences of clinicians who use these electronic record improve the hospice and palliative content in the tools in their care for seriously ill patients and the USMLE Step exams. impact of these innovations on patients.

Eliciting, Documenting, and Honoring Targeted Therapy Jeopardy: An On-Target Patient’s Goals of Care and Life-Sustaining Update (FR480) Treatment Decisions: Building Systems to Eric Prommer, MD HMDC FAAHPM, Greater Los An- Ensure Success (FR479) geles Healthcare, Los Angeles, CA. Mary Buss, MD, Shaida Talebreza, MD HMDC FAAHPM, University of Beth Israel Deaconess Medical Center, Boston, MA. Utah, Salt Lake City, UT. Jill Lowery, PsyD, National David Hui, MD MS MSC, MD Anderson Cancer Cen- Center for Ethics in Health Care, Veterans Health ter, Houston, TX. Arif Kamal, MD MHS MBA Administration, Durham, NC. Rachelle Bernacki, MD FAAHPM, Duke Cancer Institute, Durham, NC. MS FAAHPM, Dana-Farber Cancer Institute, Boston, Objectives MA. Learn the mechanisms of action for targeted and Objectives immune therapies. Describe gaps in the current health care system Identify and manage adverse effects associated that serve as barriers to honoring patient’s goals with targeted and immune therapies. of care and life-sustaining treatment decisions. Recognize clinical responses of these agents and Describe steps required to ensure that goals of how they differ from traditional chemotherapy. care conversations and life-sustaining treatment New cancer therapies such as targeted therapies and decisions are documented and honored. immune therapies attack the machinery of cancer cells Vol. 53 No. 2 February 2017 Schedule With Abstracts 385

that regulate tumor growth, progression, and survival. Described how NLP may facilitate population- These therapies have been added onto chemotherapy based palliative care research. or have replaced chemotherapy based on molecular Original Research Background. Medical notes and characteristics of the cancer. The onslaught of new reports in the electronic health record (EHR) treatments with confusing names, unusual response describe the complete picture of a patient’s experi- patterns, and unusual adverse effects overwhelms ence, including symptoms and concerns as well as re- even most oncologists. For palliative care specialists sponses to treatment plans. In addition to subjective it can be challenging to understand how these agents descriptions, text data may also contain important sometimes change the ‘‘rules’’ for how treatment is physiological descriptors, not otherwise stored in the evaluated by oncologists and may affect options with EHR as discrete data points. Currently, palliative care regard to symptom management as well as counseling researchers rely on manual chart review to extract vari- regarding decision-making about treatments. ables embedded in medical notes. This method is la- Improved knowledge of these agents enhances pallia- bor intensive and risks human error. Natural tive care participation in the care of patients using Language Processing (NLP) enables computers to these agents. This session will be presented by a panel process unstructured text data. of palliative oncologists with stated goal of providing Research Objectives. To validate NLP in a palliative on the spot learning by didactic and short clinical pre- care setting, we tested how well NLP could identify sentations and creating an easily accessible reference heart failure patients who decline following Cardiac for the clinician encountering these agents. The Resynchronization Therapy (CRT). attendee will quickly learn essentials which they can Methods. We examined EHR data from a retrospec- immediately bring into clinical care. By directly tive cohort of 970 consecutive CRT patients. Python involving the audience after each session, participants NLP was used to extract left ventricular ejection frac- and audience will learn key items related to the man- tion (LVEF) from cardiology reports and these find- agement and mechanisms of action of these agents. ings were compared to the result of manual chart The presentation session will be divided into 4 ses- abstraction in the same population. Progressive heart sions. Each session will be started with on the point di- failure was defined as <5% improvement in LVEF dactics and finish with a jeopardy session with one-year post CRT. audience participation. The session will cover: 1.) Results. Using NLP, we analyzed 50,796 cardiology Mechanisms of action of targeted and immune thera- reports and identified 579 patients with baseline pies; 2.) Adverse effects of targeted and immune ther- and one-year LVEF measurements of whom 261 apies and their management; 3.) Clinical responses of (45%) met criteria for progressive heart failure. We these agents and how they differ from traditional compared these results to a published manual chart chemotherapy and 4.) An overview of where these review of the same cohort and found 18% discor- agents fit in common malignancies. New agents on dance between manually and NLP extracted LVEF. the horizon will be discussed. Heart failure patients often have multiple LVEF mea- surements in the year following CRT implant. Human data extraction biased towards selecting the highest Paper Session follow up value which inflated CRT success rate. In contrast, NLP consistently selected the LVEF mea- surement most proximal to one-year post CRT implant. Natural Language Processing: An Conclusion. Opportunity to Make Chart Data Come NLP is a rapid method to extract text Alive in Palliative Care Research (FR481A) embedded data for palliative care research. NLP may also help reduce biases in data collection. Charlotta Lindvall, MD PhD, Dana-Farber Cancer Implications for research, policy or practice. Institute/Harvard, Boston, MA. Alexander Forsyth, NLP MEng student, Massachusetts Institute of Technology, may help scale data collection for palliative care Cambridge, MA. Regina Barzilay, PhD, MIT, Cam- research. bridge, MA. James Tulsky, MD FACP FAAHPM, Dana- Farber Cancer Institute, Boston, MA. Survival and Disposition of Patients 75 Objectives Years or Older Following Mechanical Describe strengths and limitations of using natu- Ventilation of 7 or More Days (FR481B) ral language processing to extract text embedded Kristina Newport, MD FAAHPM, Hospice & Community data for palliative care research. Care Lancaster PA, Lancaster, PA. Thomas Miller, MD, 386 Schedule With Abstracts Vol. 53 No. 2 February 2017

Hospice & Community Care, Lancaster, PA. Robin clinicians may utilize these data to better advise Hicks, DO, Heart of Lancaster Regional Medical Cen- elderly patients and researchers may use them as a ter, Lititz, PA. Sarah Svetec, BA pending, Haverford basis for further research on the appropriate College, Haverford, PA. Lisa Estrella, MS, Lancaster use of mechanical ventilation in patients age 75 or General Health/Penn Medicine, Lancaster, PA. Mike older. Horst, PhD MPHS, MS, Lancaster General Hospital, Lancaster, PA. Shanthi Sivendran, MD, Penn Medicine at Lancaster General Health, Lancaster, PA. The Self-Care Practices of Family Objectives Caregivers of High Mortality Cancer Describe mortality and disposition of patients 75 Patients: Differences by Varying Levels of years or older who require mechanical ventilation Caregiving Well-Being and Performance 7 or more days. (FR481C) Describe implications of high mortality, depen- James Dionne-Odom, PhD RN, University of Alabama dent care and readmission rates on decisions at Birmingham, Birmingham, AL. Wendy Demark- regarding mechanical ventilation for patients 75 Wahnefried, PhD RD, University of Alabama at Bir- years or older. mingham, Birmingham, AL. Richard Taylor, DNP Background. When elderly patients are intubated for CRNP ANP-BC, University of Alabama at Birmingham a week or more, decisions regarding additional aggres- School of Nursing, Birmingham, AL. Gabrielle Roc- sive support such as tracheostomy or feeding tube que, MD, University of Alabama at Birmingham, Bir- placement are based on expectations of recovery. For mingham, AL. Elizabeth Kvale, MD, University of patients over age 75 years, little data is available on the Alabama at Birmingham Center for Palliative and Sup- effect of intubation $7 days on mortality or care needs. portive Care, Birmingham, AL. Maria Pisu, PhD, Uni- Research Objective. Determine mortality and dispo- versity of Alabama at Birmingham, Birmingham, AL. sition of patients 75 or older who require $7 days of Edward Partridge, MD, University of Alabama at Bir- mechanical ventilation. mingham, Birmingham, AL. Marie Bakitas, DNSc Methods. Electronic medical records (EMR) from NP-C FAAN, University of Alabama at Birmingham, one community health system were reviewed, retro- Birmingham, AL. spectively, for outcomes and covariates. Public Objectives internet searches were performed to determine date Describe the self-care behaviors of family care- and location of death if not in the EMR. givers of high-mortality cancer patients that are Results. 88 patients aged 75 or older required me- associated with poor well-being and performance. chanical ventilation for $7 days from 5/1/11 to 4/ State possible reasons why caregivers with low 30/15. 46.5% of patients died in hospital while engagement in self-care may concurrently have 76.1% died within one year of discharge. Of those poor well-being and performance. discharged alive, the vast majority (93.6%) required Original Research Background. Caregivers of indi- care in a facility. Only 3.4% of patients returned viduals with high-mortality cancer perform vital tasks home after discharge and 2/3 of them had hospice that may disrupt their health-preserving self-care services. None of the patients returned home practices, such as eating healthy, staying physically completely independent. 47.6% of surviving patients active, getting adequate rest, balancing solitude were re-hospitalized within 1 year. 87.5% of patients and social interaction, and staying spiritually in the study died or were re-hospitalized within 1 connected. year. Research Objectives. We assessed differences in Conclusion. Patients 75 years or older have high caregiver self-care practices associated with varying mortality and caregiving needs following $7 days of levels of caregiver well-being and performance. mechanical ventilation, with no patients able to live Methods. Cross-sectional mail survey within eight independent from medical services immediately after community-based Southeastern U.S. cancer centers. hospital discharge and only 24% surviving 1 year Family caregivers of Medicare beneficiaries $65 later. years with pancreatic, lung, brain, ovarian, head & Implications for Practice, Policy and Re- neck, hematologic, or stage IV cancer completed search. Based on these data, elderly patients may measures of self-care practices (health responsibil- decide against initial or prolonged intubation, or ity, physical activity, nutrition, spiritual growth, tracheostomy and feeding tube placement. Critical interpersonal relations, stress management, and care providers, hospitalists and palliative care sleep), well-being (anxiety, depression, and health- Vol. 53 No. 2 February 2017 Schedule With Abstracts 387

related quality of life [HRQoL]), and performance palliative care. Our purpose was to test Managing Can- (caregiver competence and preparedness and deci- cer Care (MCC), an intervention to improve patients’ sion-making self-efficacy). Differences in individual knowledge and integration of palliative care into self-care practices were calculated using Kruskal- breast cancer self-management. Wallis test by tertiles of well-being and caregiver Research Objectives. We evaluated effects of MCC performance. on patients’ knowledge of palliative care among other Results. Caregivers (n¼294) averaged 66 years, were care options (curative and hospice care), behaviors mostly female (72.8%), white (91.2%), Protestant (role in self-management, goals of care conversations, (76.2%), retired (54.4%) and patients’ spouse/part- medical communication, management of transitions, ner (60.2%). Approximately half were rural-dwellers health care utilization) and feelings (self-efficacy, anx- (46.9%) with incomes <$50,000 (53.8%). Most pro- iety, depression, uncertainty). vided support 6-7 days/week (71%) for >1 year Methods. In this pilot RCT, we enrolled patients with (68%). Nearly a quarter (23%) reported high Stage I-IV breast cancer receiving any type of treat- depression and 34% reported borderline or high ment. We gave the intervention group MCC and anxiety. Low engagement in all self-care practices gave the control group a symptom management tool- was associated with worse caregiver anxiety, depres- kit. MCC is a set of seven printed modules covering sion, and mental HRQoL (all p-values<.05). Care- care options, self-management, communication with givers with lower health responsibility, spiritual family and providers, transitions, self-efficacy, and growth, interpersonal relation, and stress manage- symptom management. We collected data at baseline, ment scores had poorer performance scores (lower one, and three months. competence, preparedness, and decision-making Results. Participants (n¼71) had a mean age of 51.5 self-efficacy). years (range 28-74). 46.5% were White and 53.5% Conclusion. A significant proportion of caregivers were Black and other minorities. Breakdown of cancer simultaneously report low engagement in all forms stage was 59.1% early (I or II) and 40.8% late (III or of self-care practices, high depression and anxiety, IV). Compared to controls and after controlling for and low HRQoL mental health scores. race, the intervention group showed a large effect Implications for research, policy or prac- size for improved knowledge of palliative care (partial tice. Caregiver well-being and performance might be ƞ2¼.127). Intervention participants with late stage optimized through interventions targeted at cancer showed medium effect sizes for increased enhancing health responsibility, stress management, desire to self-manage and for reduced anxiety and interpersonal relationships, and spiritual growth self- depression (partial ƞ2¼ .05, .05, .07, respectively). care practices. Conclusion. MCC appears to be more effective among patients with late stage cancer. Implications for research, policy or pra- ctice. Further study among a larger sample is needed Cancer Stage Makes a Difference: Results to explain the relationship between breast cancer from a Pilot RCT Integrating Palliative Care stage and self-management outcomes. into Breast Cancer Self-Management (FR481D) Dena Schulman-Green, PhD, Yale School of Nursing, West Haven, CT. Sarah Linsky, MPH, Yale University, 4:30e6:30 pm West Haven, CT. Catherine Adams, MD PhD, St. Pe- ter’s Hospital, Albany, NY Orange, CT. Sangchoon Interactive Educational Exchange (FR482) Jeon, PhD, Yale University, West Haven, CT. Objectives Name three specific aims of the pilot RCT of the Autopsy Conference Collaboration: A Managing Cancer Care intervention. Memorable Inter-Professional Learning Identify key outcomes of the pilot RCT of the Opportunity Managing Cancer Care intervention. Karen Blackstone, MD, Washington DC Veterans Af- Identify differences in outcomes of the pilot RCT fairs Medical Center, Washington, DC. Anca Dinescu, by stage of breast cancer and race. MD, Washington DC Veterans Affairs Medical Center, Original Research Background. Many cancer pa- Washington, DC. Edina Paal, MD, Washington DC Vet- tients remain unaware of the nature and benefits of erans Affairs Medical Center, Washington, DC. 388 Schedule With Abstracts Vol. 53 No. 2 February 2017

Elizabeth Cobbs, MD, Washington DC Veterans Affairs Conclusion. Person-centered autopsy conferences Medical Center, Washington, DC. present unique and memorable learning opportu- Objectives nities to improve end-of-life care, communication, in- Recognize autopsy as an opportunity for palliative ter-professional teamwork, and personal reflection. care inter-professional education. Collaboration between decedent affairs, palliative, Describe the elements of a successful autopsy con- and pathology teams enhances autopsy rates. This pro- ference program. gram may be readily adapted to other hospital training Background. Autopsies provide valuable information program sites. We will share our coaching tools, chal- for families and health care providers. Palliative Care lenges, and successes. teams are increasingly involved in the care of dying hospitalized patients and may be catalysts in request- ing autopsies and organizing conferences. Methods. A palliative provider speaks with most fam- Raising the Bar: Applying a Mastery ilies after the death, to share condolences of the team Learning Approach to Communication Skills and discuss autopsy benefit. A coaching tool has been Training developed for decedent affairs staff. When family con- Julia Vermylen, MD MPH, Northwestern University, sents, a post-autopsy conference is coordinated with Chicago, IL. Gordon Wood, MD MSCI FAAHPM, invitations to treating hospitalist and specialist teams, Northwestern University, Chicago, IL. Diane Wayne, as well as to all inter-professional trainees rotating in MD, Northwestern University, Chicago, IL. William palliative care/geriatrics. A palliative medicine physi- McGaghie, PhD, Northwestern University, Chicago, cian and a pathologist lead a thirty-minute conference IL Elaine Cohen, MEd, Northwestern University, Chi- in the morgue including discussion of the patient’s cago, IL. clinical course and a ‘‘hands-on’’ review of the gross Objectives pathologic findings of the major organs. Faculty lead Develop a checklist to assess the quality of a BBN the discussion based on specific patient concerns conversation. and general topics of prognostication, symptom man- Develop a BBN mastery-learning curriculum. agement, communication with families before/after Background. Small group role play methods, such as death, benefits of autopsy, and autopsy procedures. those developed by VitalTalk, have become the stan- Faculty facilitate reflection on person-centered care, dard at many sites for teaching communication skills. grief and bereavement. Recent data, however, showed that these methods did Results. 30% of families consented to autopsy (Jan- not improve patient-level outcomes and had some Jun 2016, 30 autopsies/99 deaths in hospital and VA negative effects. One possible explanation is that nursing home). The rate of consent increased from some learners may have completed the training but 22% the previous year after the coaching tool was im- did not acquire sufficient skills to transfer to later pa- plemented. More than one hundred conference at- tient encounters. Mastery Learning is an educational tendees included: Palliative Medicine/Geriatrics methodology where learners engage in deliberate faculty and fellows, Pathology faculty and fellows, in- practice until they reach a Minimum Passing Standard ternal medicine and family medicine residents (MPS). In the mastery model, time varies while (PGY1-3), medical students, nurses and nurse practi- learning outcomes are uniform. tioner students, pharmacy students, social workers In this study, we sought to apply Mastery Learning and social work students. Most reported no experi- principles to small group communication skills ence in autopsy viewing and discomfort talking with training in breaking bad news (BBN). families about consenting for autopsy. Methods. A panel of 12 education and palliative care Discussion. Faculty, staff and trainees reported the experts convened to review the literature and develop experience as memorable and appreciated opportu- a new gold-standard assessment tool that could be im- nity to examine organs thoroughly and discuss their plemented in a Mastery Learning model. A pilot own challenges and barriers in caring for dying pa- group of fourth-year medical students completed a tients and communicating with families. Those who pretest simulated patient encounter and received had experienced ‘‘anatomy lab’’ or a single autopsy feedback based on the checklist. After a 4-hour session as a student reported the experience as extremely featuring 3 hours of communication skills practice, rich, to have followed clinical medical training, ‘‘it’s students completed a posttest simulated patient fantastic to see and touch now that I actually am tak- encounter using the same assessment tool. An expert ing care of patients.’’ panel then convened to review the data from the Vol. 53 No. 2 February 2017 Schedule With Abstracts 389

testing to set the mastery MPS using the Angoff and is significant untapped demand for rigorous PC ed- Hofstee methods. ucation options for mid-career providers who need Results. A 15-point checklist and 3 global rating scale to stay in their community and practice. Our newly questions were developed. During the pilot interven- developed Master of Science in Palliative Care tion, students (N¼16) improved from a mean of (MSPC) will prepare healthcare providers (nurses, 62.0% (SD 16.1%) to 83.75% (SD 10.6%) (p < pharmacists, physicians, and physician assistants) to 0.001) on the checklist and from a mean simulated pa- become Palliative Care Community Specialists tient-rated quality of communication (QOC) score of (PCCS). 5.4 (SD 2.17) to 6 (SD 0.96) (p ¼ 0.34) on a scale of Methods. A 36-credit hour MSPC program has been 0-10. The expert group set the MPS at 80% of the designed to be completed over 24 months of contin- checklist items correct and at least a score of 6 on uous study. Students may choose flexible completion the QOC score. During this academic year, students options; courses are currently offered once per aca- will complete deliberate practice of BBN skills until demic year. Education will include: they achieve the MPS. Case-based learning and problem-solving meth- Discussion. A rigorous curriculum for medical stu- odologies within a caring framework of PC ap- dents produced significant improvement in BBN con- proaches encompassing the whole person; versations. Future work will involve assessing the Intensive education and practice in communica- impact of BBN mastery learning on patient-level tion skills; outcomes. Pain and non-pain symptom assessment and Conclusion. Integrating small group role play into a management; Mastery Learning model is feasible. Boosting BBN Interdisciplinary team support for psycho-social- communication skills to uniformly high levels may spiritual distress; potentially yield a more robust impact on patients Ethical principles and decision-making and families. methodologies Results. Seventeen students representing all disci- Master of Science in Palliative Care: On plines have enrolled; classes begin August 2016. Becoming a Palliative Care Community Extensive evaluation has been integrated. We will Specialist report on student learning and reaction to learning F. Amos Bailey, MD, University of Colorado, Aurora, of the first two courses: Palliative Care Concepts and CO. Regina M. Fink University of Colorado, Aurora, Communication Skills (on-line with on-campus inten- CO. Shaun Gleason University of Colorado, Aurora, sive) and Basic Pain Management with IDT Care (on- CO. line). Objectives Discussion. PCCSs will receive education and skill Develop a case-based on-line interprofessional PC development enabling them to provide high quality educational program for mid-career working pro- PC to patients/families in the community whose fessionals who wish to provide high quality PC in needs are greater than can be provided by Primary their community. Care Providers, and neither need nor desire care in Use patient/family/provider dialogues to ground an academic tertiary medical center. The PCCS will on-line education in the clinical experience. be linked to tertiary PC experts, creating a network Provide an educational experience with a woven of PC services that may better support the needs of pa- curriculum of bio-medical content and psycho-so- tients/families throughout the care continuum across cial-spiritual-ethical and communications lessons settings. to replicate in-person preceptorship. Conclusion. We have found there is a need and de- Define a PCCS as a provider of high-quality mand for educational options to expand PC services. consultative PC outside an academic setting. The PCCS may be an important part of the solution Background. Workforce issues related to an inade- to the workforce deficit issue. quate supply of physicians and other providers educated in Palliative and Hospice Care are well documented. The recent IOM report called for The ‘‘Opioid Square’’: A Novel Educational alternative and expanded training opportunities for Tool for Making Opioid Conversions providers to expand the workforce and supplement Heidi Young, MD, Georgetown University Hospital, primary palliative care (PC) across all settings. There Washington, DC. James Shear, MD, Virginia Hospital 390 Schedule With Abstracts Vol. 53 No. 2 February 2017

Center, Arlington, VA. Yvonne Hernandez, PhD, Geor- helping students make accurate conversions. As getown University School of Medicine, Washington, many students preferred the ‘‘Square,’’ this tool may DC. Peggy Compton, PhD RN FAAN, Georgetown provide educators with an alternative visual framework University School of Nursing and Health Studies, for teaching opioid conversions. Washington, DC. Objectives Determine the degree to which the ‘‘Opioid Use of Google Glass to Enhance Square’’ tool assists 2nd year medical students in Communication Education Laura Dingfield, MD, Hospital of the University of correctly calculating opioid conversions. Pennsylvania, Philadelphia, PA. Stacey Kassutto Hospi- Evaluate the student’s preference to use the tal of the University of Pennsylvania, Philadelphia, PA. ‘‘Opioid Square’’ in comparison to the classic equi- Jessica Dine Hospital of the University of Pennsylva- analgesic tables to calculate opioid conversions. nia, Philadelphia, PA. Background. Equianalgesic conversions between opioid drugs and oral and intravenous formulations Objectives are a clinically important skill, for all practitioners Use Google Glass to enhance communication ed- who treat pain. Accuracy is critical to preventing ucation and provide feedback. serious adverse events. Opioid conversion tables are Assess feasibility of using Google Glass in a simu- a commonly used tool for teaching this skill, however lated setting. a needs assessment at our institution reveals the classic Assess trainee perceptions of video recording of conversion table is difficult for learners to understand. goals of care discussions. A novel visual tool, the ‘‘Opioid Square’’ was devel- Background. Behavioral modeling, direct observa- oped to provide a different visual framework for tion, and use of standardized patients are the primary opioid conversions. strategies used to educate trainees on having goals of Methods. The sample consisted of 200 students at a care conversations. Incorporation of technology like single academic institution who were learning Google Glass may offer novel mechanisms to enhance opioid conversions for the first time during their communication, education and provide feedback. Lit- Pharmacology class. Students were taught conver- tle is known about perceptions of video recording to sions using both the standard conversion table, enhance communication education and provide and the ‘‘Opioid Square’’ method. An eight item formative feedback. conversion quiz followed, on various opioid drugs Methods. Thirty-four second and third year medicine and formulations of each. Students were allowed to residents participated in a half-day goals of care use either tool and preferences were assessed with communication workshop, with presentation of a qualitative comments. framework for discussing goals of care and two role Results. 187/200 students participated in the study. play exercises. One role play exercise was enhanced Accuracy of the eight conversion questions was gener- using Google Glass. Patient actors wearing Google ally good (85%-100% correct), and without any statis- Glass recorded interactions with participants. Resi- tical differences in accuracy between the Square and dents completed pre and post-workshop surveys, and the Table. Incorrect conversions were more likely on also participated in a structured focus group two-step problems (i.e., IV fentanyl to oral morphine). regarding their impressions of current opportunities A slight majority of students (53%) indicated that they for communication education and Google Glass video preferred the ‘‘Opioid Square’’ over the Conversion recording. Table, and 35% noted they would prefer to use both Results. Twenty-three residents completed the pre- tools if given the option in the future. workshop survey and 17 completed the post-work- Discussion. Providing an alternative visual tool to the shop survey. Increased confidence in discussing classic opioid conversion table was well received by stu- goals of care was reported by 76% (13/17) of resi- dents in this study. Our presentation will include an dents. Residents were ambivalent about whether ‘‘Opioid Square’’ pocket card and explanation of Google Glass enhanced their educational experi- how to use and teach this method in other ence during simulation, with 82% (14/17) report- institutions. ing neither positive nor negative impressions. Conclusion. The novel ‘‘Opioid Square’’ tool is not Forty-seven percent (8/17) of residents reported inferior to the classic opioid equianalgesic table for comfort with video recording using Google Glass Vol. 53 No. 2 February 2017 Schedule With Abstracts 391

in simulated settings, and 41% (7/17) thought they Background. Americans are receiving aggressive care would be comfortable recording real patient-care at the end of life, which is often contrary to their values conversations. Themes that emerged during the and goals. Their providers often lack either training in focus groups included concern that video recording goals of care communication or the time necessary to of simulated or real-world patient encounters may have those discussions. Use of ICU in the last months change physician or patient behavior during these of life is increasing while average length of stay on hos- sensitive discussions, and concern with creation of pice is decreasing. To increase access to goals of care a permanent video record to use for evaluative discussions, we developed Advanced Illness Care, a purposes. nurse care manager program designed for patients in Discussion. Google Glass is simple to incorporate the last 1-2 years of life. into simulated communication education for Methods. We developed a blended learning model trainees, and this workshop could be adapted for to train the care managers. This involved 2 books use at other institutions to increase trainee confi- and 5 web based courses that participants completed dence in having goals of care discussions. Google prior to coming to a 2 day in-person training. The Glass recordings could be helpful in providing modules were designed by instructional designers point-of-view feedback on verbal and non-verbal along with a content expert and covered: advanced communication. Although impressions of use of careplanning,hospice,prognosis,symptomman- Google Glass and video recording were mixed, this agement and ethics and culture. The in-person technology has the potential to offer new opportu- training was interactive and used a board game, nities for provision of formative feedback on role-play, cases, and small group discussions. The lec- communication skills in a variety of patient care ture component was minimal. The ‘‘Fragility of Life’’ settings. activity asked participants to care for a raw egg during their 2 days of training to demonstrate the intensity Conclusion. More work needs to be done to of managing a patient in advanced illness. Kindle tab- understand how to incorporate new technology, like lets were given to each small group that contained a Google Glass, into communication education and ‘‘story-sync’’ that threaded an interactive patient evaluation. case throughout the training to give real-life exam- ples of the topics. Advanced Illness Care Training for Nurse Results. Thirty nurses, social workers, and NP/PAs Care Managers completed the first training in late July 2016 and the program launched officially in August 2016. Rebecca Yamarik, MD MPH, Evolent Healthcare, Ar- The training was well received by the participants, lington, VA. Nancy Lentz, MSN BSN, Evolent Health- praised particularly for the interactive components. care, Arlington, VA. Matt Estes Evolent Healthcare, By the time of the conference we will have data to Arlington, VA. Scott La Forte Evolent Healthcare, Ar- share. The training is being revised based on partici- lington, VA. pant feedback to improve the story sync and board Objectives game. Prognosticate patients in the last 1-2 years of life. Discussion. The training is being revised based on Understand the symptoms associated with participant feedback to improve the story sync advanced illness and their treatments. and board game. Working with instructional Explore goals of care in a culturally sensitive designers with a background in web education manner with advanced illness patients and their enhances the educational experience for families. participants. Deal successfully with difficult situations Conclusion. A blended learning model, where partic- such as patients/families who ‘‘want every- ipants gain knowledge using web-based courses prior thing done’’ and suspected abuse and to a classroom component, is an effective method neglect. for teaching Palliative Care. 392 Schedule With Abstracts Vol. 53 No. 2 February 2017

Saturday, February 25 Gain insight into the clinical implications of the early palliative care model. 8:15e10 am Patients with advanced cancer experience both physical and psychological symptoms due to their Plenary Sessions illness. Their family caregivers are also significantly impacted by their disease and experience distress surrounding their loved one’s diagnosis. Patients The State of the Science: Update in Hospice with advanced cancer and their family caregivers and Palliative Care (104) also face difficult communication about their prog- Nick Dionne-Odom, PhD RN ACHPN, University of nosis and end of life care. Unfortunately, data sug- Alabama at Birmingham School of Nursing, Birming- gest that the majority of patients with advanced ham, AL. Cardinale Smith, MD PhD, Icahn School cancer hold overly optimistic perceptions of their of Medicine at Mount Sinai, New York, NY. prognosis and only engage in discussions about Objectives their end of life care preferences late in their illness. Summarize selected important peer-reviewed arti- Based upon the experiences of these patients and cles from the last year. their families, earlier involvement of palliative care Critique the methodologies and understand the services may improve their quality of life and care. conclusions of these articles. Several randomized trials demonstrate that early Determine if the findings are relevant to the pa- involvement of palliative care in the outpatient tients for whom the attendee cares. care setting improves both patient and family care- The objective of this session is to review the journal ar- giver outcomes. Specifically, early palliative care im- ticles published during the last year with the highest proves patients’ quality of life, mood, prognostic potential for impact on the field of hospice and palli- awareness, coping, and communication about end ative medicine. A hand search of leading journals of life care preferences. Importantly, early palliative highly relevant to the practice of hospice and palliative care also improves the delivery of end of life care care was supplemented with a search of evidence with less chemotherapy administration at the end based reviews, a targeted keyword search, and conver- of life and earlier referrals for hospice services. Fam- sations with experts in the disciplines of medicine, ily caregivers also benefit from early palliative care nursing, and social work. Journal articles were re- with lower rates of depression and improved quality viewed for both study quality and potential for imme- of life. However, questions remain about how to diate impact on the field of hospice and palliative measure the impact of early palliative care, how to care. There was a selection bias against descriptive best integrate palliative care across cancer popula- studies, pilot studies, pre-clinical studies, retrospective tions, and how to disseminate palliative care services studies, open-label trials, case-series, instrument vali- in the face of limited resources. Implementing palli- dation studies, and confirmatory analyses. ative care in the outpatient care setting also requires operational oversight and support and collaboration with oncology. 10:30e11:30 am

Concurrent Sessions We’re Stuck! Please Help!! Palliative Care to ‘‘The Goals of Care’’ Rescue (SA501) Erin Stevens, DO, Stanford University Medical Center, Integrating Palliative and Oncology Care: Stanford, CA. Michael Westley, MD FACP FCCP, Stan- Where Do We Go from Here? (SA500) ford University, Palo Alto, CA. Scientific Research Award Winner. Jennifer Temel, Objectives MD, Harvard Medical School, Massachusetts General Describe a ‘‘differential diagnosis’’ of how pa- Hospital Cancer Center, Boston, MA. tients/families use information and how they Objectives ‘‘process’’ it to make difficult choices. Be familiar with unmet palliative care needs in pa- Identify methods and tools for Palliative Care cli- tients with advanced cancer. nicians to better understand the patient/family Understand data on benefits of early palliative perspective of their decisions. care and unanswered questions about how to inte- Recall methods to assist patients/families to move grated palliative care. forward once their perspective is clear and recog- Vol. 53 No. 2 February 2017 Schedule With Abstracts 393

nize when to ask for additional assistance when a dosage formulation, it can be hard to commit to these methods seem ineffective. medication decisions. Two pharmacists will speed- Requests to clarify GOC are among the most date their way through medication tips designed to frequent reasons Palliative Care is consulted and highlight important and little known medication facts ability to lead these discussions is a key competency that are important in palliative medicine. Topics to be milestone for Palliative Care Fellows. Some pa- covered include: determining appropriate mainte- tients/families clarify their choices easily and not nance medications, side effects such as hypogonadism all need the expertise of Palliative Care. On occa- with opioids, alternate administration of oral medica- sion these conversations are complex with both pa- tions, using topical products, tips for maximizing tients/families and the care team struggling. dosing of patches, buccal vs transmucosal administra- Challenging GOC conversations have many dimen- tion, medications that you can crush vs dissolve, and sions and benefit from the communication skillful- more! Find a tip that you are compatible with that ness of Palliative Care clinicians. may just change your life. In this interactive, case-based session we will explore the more challenging GOC conversations, specif- Pay-for-Quality Is Here: Now What? ically focusing on how patients with their families (SA503) make difficult, often life-changing choices under Phillip Rodgers, MD FAAHPM, University of Michi- uncertainty and how Palliative Care clinicians can gan, Ann Arbor, MI. Arif Kamal, MD MHS MBA become better guides and coaches. We will demon- FAAHPM, Duke Cancer Institute, Durham, NC. strate how insight from cognitive psychology and Objectives neuroscience will lend an understanding to this Describe the current and immediate future state decisional framework and how this knowledge will of value-based reimbursement (VBR or ‘‘pay-for- add to the Palliative Care clinician’s skills. We will re- quality’’), including the Merit Incentive Payment view best practices for determining and communi- System (MIPS), Alternative Payment Models cating risk and prognoses and discuss how (APMs), and others. patients/families interpret this information and Summarize key features of quality measurement incorporate it into their decisions. Using case exam- tools that can position palliative care clinicians ples throughout the work shop, we will demonstrate to participate successfully in VBR paradigms. methods to better understand where patients and Evaluate, modify or explore development of your families seem ‘‘stuck’’ and tools to guide them to own quality measurement strategy to meet the move forward. current and future realities of pay-for-quality. Value-based reimbursement (VBR) is now a reality in Love Me ‘‘Tinder’’: Speed Dating with the the US healthcare system. Driven by a rising impera- Pharmacy Ladies (SA502) tive to improve health care for patients and popula- Kathryn Walker, PharmD BCPS CPE, Medstar Health, tions while controlling cost growth, payment systems University of Maryland School of Pharmacy, Balti- are changing rapidly to incentivize care that improves more, MD. Mary Lynn McPherson, PharmD BCPS quality, reduces cost, or both. CPE, University of Maryland School of Pharmacy, Bal- The Centers for Medicare and Medicaid services timore, MD. (CMS) continues to implement elements of the Objectives Medicare and CHIP Reauthorization Act (MACRA) Discuss 3 pearls related to pharmacology of palli- to drive VBR, including creating two payment path- ative medications. ways in the Medicare fee-for-service system: the Discuss 3 pearls related to appropriateness of Merit-Based Incentive Payment System (MIPS) and maintenance medications in EOL care. Alternative Payment Models (APMs). Both the Discuss 3 pearls related to using palliative medica- MIPS and APM pathways create both significant pay- tions in a safe and effective manner. ment incentives for quality measurement and per- After ‘‘meeting’’ in 2012, a bond has formed and new formance,aswellassignificantpaymentlossfor tips are on the way for Round Five. Complex medica- failure to do so. Medicare Advantage and other com- tion decisions are an integral part of treating palliative mercial payers are adopting analogous ‘‘upside/ care patients. Pharmacists have a unique perspective downside’’ payment systems to inform their VBR on using these medications creatively and effectively. paradigms. This one hour session will flirt with tips and tricks This session will feature leading national experts in on using medications appropriately for patients facing palliative care quality measurement and payment, advanced diseases. Whether debriding a medication who will discuss the impact of VBR on palliative care profile, aggressively treating symptoms or strategizing providers and practices. Topics will include: details 394 Schedule With Abstracts Vol. 53 No. 2 February 2017 of MIPS and APMs relevant to palliative care pro- Measuring What Matters for Families and viders; specific considerations for quality measure- Caregivers: But How? (SA505) ment and reporting in palliative care; and options Rodney Tucker, MD MMM FAAHPM, University of for palliative care providers and programs to evaluate, Alabama at Birmingham Center for Palliative and Sup- modify or develop quality strategies to meet reporting portive Care, Birmingham, AL. Ashley Nichols, MD, requirements for VBR participation. University of Alabama at Birmingham Hospital, Bir- Participants will then be invited to share their own ex- mingham, AL. Katherine Ast, MSW LCSW, American periences with quality measurement and reporting Academy of Hospice and Palliative Medicine, Chicago, strategies, and/or VBR programs. Our presenters IL. Christopher Brainard, MSHA FACHE, University will serve as a panel to respond and stimulate discus- of Alabama at Birmingham Health System, Birming- sion about best practices, and overcoming barriers to ham, AL. success. Objectives Define the barriers and opportunities associated with measuring family and caregiver satisfaction The Write Stuff: How to Increase Your with palliative care services in inpatient and Writing Productivity (SA504) ambulatory settings. Irene Yeh, MD MPH, Dana-Farber Cancer Institute, Review the Measuring What Matters (MWM) proj- Boston, MA. Barbara Reville, DNP ANP-BC ACHPN, ect within AAHPM and the unique challenges in Dana-Farber Cancer Institute and Brigham & this arena. Women’s, Boston, MA. Delineate the next steps in linking palliative care Objectives patient and family experience data and measure- Identify common challenges that are faced when ment to hospitals that are focused on patient starting or completing a writing project. perception of care surveys. Demonstrate how to form a writing accountability As the provision of palliative care (PC) services in group (WAG). inpatient care settings grows, the need for standard- Explore different writing exercises to improve ized methods of obtaining patient and family satisfac- overall writing fitness. tion data will be increasingly important. This has been Many of us encounter challenges in writing when the highlighted in the Measuring What Matters project stakes are high. Starting and completing a journal within AAHPM and in several large healthcare organi- article, business plan, or even a conference abstract zations. Measurement of ‘‘satisfaction’’ or experience can be difficult for many reasons. Participants in this with PC services can be difficult since families of pa- session will explore common writing barriers and tients who die in these settings do not receive stan- how to overcome them and establish good writing dardized surveys as a matter of routine. habits. While writing is ultimately a solitary activity, Furthermore, live patients who are seen by PC teams there is evidence that joining with other motivated may be surveyed in small quantities insufficient to writers can facilitate achievement of your writing determine any positive effect. Consistent and quantifi- goals. able measurement can highlight the role, effective- All writers, whether famous or unknown, deal with ness, and value added of PC services in the realm of writing blocks such as lack of ideas, time constraints, patient experience for hospitals. or a harsh inner critic. While the challenges of the in- Hospital Consumer Assessment of Healthcare Pro- dividual writer are personal, there are effective strate- viders and Systems (HCAHPS) surveys which are gies to exercise your writing ‘‘muscles.’’ Just as an mandated by CMS and the subsequent Value Based athlete practices regularly to improve performance, es- Purchasing (VBP) payment system has brought tablishing a regular writing practice can increase pro- increased attention to the potential effects of quality ductivity and creative expression. PC services through an emphasis on communication This session will be both informative and interactive. skills, coordination of care, pain management and Individual writing and group brainstorming will goals of care discussions. This session will highlight help participants share and discover strategies to un- the experience of a large academic setting attempting block their writing and find a writing voice. Group to use a standardized bereavement or caregiver survey work will focus on how to form a writing account- through a national vendor and will link the impor- ability group at one’s workplace to overcome the tance of continued efforts in this realm. Attendees isolation of writing and improve one’s writing pro- will be better equipped to link the potential benefits ductivity. of measuring PC experience to hospitals overall Vol. 53 No. 2 February 2017 Schedule With Abstracts 395

experience and will also be provided with a check list significant impact on participants. Formal evaluation of key questions to return to their organizations data support that Rounds participants report administration to help guide future efforts around increased insight into psychosocial aspects of care, this type of data collection. enhanced compassion, and increased ability to respond to patients’ social and emotional issues. Par- Resilience, Compassion, and ticipants also report how Rounds have helped them Communication: How the Schwartz Center develop skills to communicate with more sensitivity Rounds Promotes Primary Palliative Care and empathy when dealing with patients and patients’ (SA506) families, which translates into better overall care. Steven M. Radwany, MD, Summa Health System, Ak- Rounds have also been a catalyst for changes in policy ron, OH. Pamela Mann, MSSA, The Schwartz Center and development of new programs within individual For Compassionate Healthcare, Boston, MA. Rod health care institutions. Myerscough, PhD, Summa Health System, Akron, OH. Aileen Jencius, MLIS, Summa Health System, Ak- ron, OH. State of the Science in Pediatric Palliative Objectives Care (SA507) Recognize the value of an interdisciplinary forum Jennifer Hwang, MD MHS, The Children’s Hospital of that promotes collaborative working relationships Philadelphia, Philadelphia, PA. Lisa Humphrey, MD, to advance patient-centered care. Nationwide Children’s Hospital, Columbus, OH. Eli- Demonstrate how these Rounds promote ssa Miller, MD, Nemours/Al DuPont Hospital for Chil- enhanced palliative care skills among attendees dren, Philadelphia, PA. Lindsay Ragsdale, MD, while promoting positive culture change and pro- Kentucky Children’s Hospital, Lexington, KY. Cheryl vider resilience in a healthcare organization. Thaxton, MSN FNP-BCCHPPN, Medical City Dallas/ Plan and promote Schwartz Center Rounds Medical City Children’s, Dallas, TX. Tiffany Webster, within your home institution borrowing from MDiv, University of California San Francisco, San Fran- the experiences of a program led by palliative cisco, CA. Nicole Parente, MSW, Nationwide Chil- care providers. dren’s Hospital, Columbus, OH. Most palliative care providers and programs struggle Objectives to grow the skill set of primary providers to help Discuss with a colleague one new article them address the basic palliative care needs of the relevant to the clinical practice of pediatric palli- growing population of patients with advanced and ative care. serious illness. Established in 1995, the Schwartz Cen- Describe a fact, skill or attitude that you are re- ter for Compassionate Healthcare is committed to considering based on the information presented promoting compassionate health care and has at this session. become nationally recognized as a vibrant and valu- Identify a clinical population that your program able organization that creates and supports ground- serves that you could write about to educate the breaking educational programs for multidisciplinary larger pediatric palliative care community. caregivers, their patients, and the health care commu- With the growth of Pediatric Palliative Care, it is essen- nity. A significant contributor to the Schwartz Center’s tial for practitioners to find ways to stay current on the success has been its landmark program Schwartz Cen- most recent literature. In the spirit of the State of the Ò ter Rounds , which offers multidisciplinary caregivers Science plenary which is part of each Assembly, the the unique opportunity to discuss social and presenters will endeavor to review the literature pub- emotional issues inherent in patient care. What began lished since 2015 which should inform the practice in 1997 at one hospital is now taking place across the of Pediatric Palliative Care. Our transdisciplinary country at over 400 health care settings across the team of co-presenters includes representatives from nation, and over 135 sites in other countries. Schwartz medicine, nursing, social work and chaplaincy and Center Rounds has become a national model for pro- will look at the academic literature relevant to the mul- ductive discussions on compassionate care and can tiple disciplines represented. In addition to high- serve as a valuable vehicle for promoting palliative lighting recent literature, the presenters hope to care precepts broadly across an integrated delivery inspire session participants to consider how new system. knowledge will influence their practice and how they Schwartz Center Rounds demonstrates how a cost- can personally contribute to the published knowledge effective and well managed program has made a base. 396 Schedule With Abstracts Vol. 53 No. 2 February 2017

Paper Session played a greater role among whites and Latinos than among black Americans. Implications for research, policy or pra- Does Expectation of Death Explain Racial ctice. Discussing prognosis by itself is unlikely to and Ethnic Disparities in Death in the address racial/ethnic disparities. Other factors appear Hospital (SA508A) to play an important role that need to be understood. Rafael Romo, PhD RN PHN, University of Virginia School of Nursing, Charlottesville, VA. Brie Williams, Apoyo con Carino:~ Patient Navigation to MD, University of California San Francisco, San Fran- Improve Palliative Care Outcomes for cisco, CA. Alexander Smith, MD MPH MS, University Latinos with Advanced Cancer (SA508B) of California, San Francisco Division of Geriatrics, Stacy Fischer, MD, University of Colorado Health Sci- San Francisco, CA. ences Center, Aurora, CO. Sung-joon Min, PhD, Uni- Objectives versity of Colorado Anschutz Medical Campus, Explain the relationship between expectation of Aurora, CO. Danielle Kline, MS, University of Colora- death and racial/ethnic differences in death in do Denver School of Medicine, Aurora, CO. Regina the hospital. Fink, PhD RN APN CHPN AOCN FAAN, University Explain how the expectation of death acts differ- of Colorado, Aurora, CO. ently among racial/ethnic groups. Objectives Original Research Background. Older black and Identify methodologic strengths and weaknesses Latino Americans are more likely than white Ameri- involving palliative care delivery research. cans to die in the hospital. These minority groups Understand the role of patient navigators to pro- may seek more hospital-based aggressive end-of-life mote and support primary palliative care in the care because they are less aware that they have a cancer care setting. limited prognosis. Original Research Background. Efforts to increase Research Objectives. To determine if family’s expec- access to palliative care (PC) must maximize primary tation of death moderates or mediates racial/ethnic PC and community-based models to meet the ever differences in site of death. growing need in a culturally-sensitive manner. Our pi- Methods. We analyzed interviews conducted after lot data suggest that a culturally tailored patient navi- death among next-of-kin who participated in the gator intervention has the potential to improve PC Health and Retirement Study, a nationally representa- outcomes for Latinos with advanced cancer. tive study of U.S. adults, and responded to the ques- Research Objectives. To conduct a multi-site ran- tion: ‘‘Was the death expected?’’ We tested for an domized controlled trial testing the effectiveness of a interaction between race/ethnicity and the expecta- patient navigator intervention to improve PC tion of death with death in the hospital and used outcomes. multivariate modeling to calculate unadjusted and Methods. Latino adults with advanced cancer were adjusted relative risk of death in the hospital by randomized to control (educational materials) or race/ethnicity. intervention (educational materials and w5 navigator Results. The sample included 5979 decedents. Over- visits). Measured 3 month outcomes: Brief Pain Inven- all, 55% were women, 79% were white, 14% black, tory, McGill QOL Questionnaire, and a process mea- and 7% Latino. Death was expected for 59% of partici- sure; 6 months: documented advance directives (AD) pants. Whites and Latinos were >15% less likely to die in in EMR; Ongoing data collection: hospice utilization, the hospital when death was expected than when it was length of stay, and aggressiveness of care at end-of-life. not; with no difference among African Americans Results. 223 patients enrolled and were randomized (interaction p<0.001). Overall compared to whites, to control (111) or intervention groups (112). Inter- blacks and Latinos were more likely to die in hospital vention group patients reported an average pain (blacks, RR¼1.24; Latinos, RR¼1.90, both p<0.001). severity score (0-10) of 2.88 (+2.52) versus control Adjusting for potential socio-demographic and health- 3.52 (+2.90), p¼0.12 and pain interference of 3.36 related confounders (age, gender, clinical prognosis) (+3.27) versus control 3.83 (+3.56), p¼0.37. Only attenuated the differences (blacks, RR¼1.23; Latinos, physical subscale showed a significant effect in QOL RR¼1.14, both p<0.001), but further adjusting for (6.86+2.53 intervention vs. 5.76+2.86 control, the expectation of death did not (blacks: RR¼ 1.21, p¼0.007). Documented AD in the EMR 69% (66) of p<0.001, Latinos: RR¼1.13, p¼0.009). intervention versus 33% (28) control, p<0.0001. Pro- Conclusion. Among a nationally-representative sam- cess outcomes: 84% of intervention patients reported ple of older adults, we found that the expectation of discussing advance care planning with families and death did not fully account for site of death and providers (60%), compared to control (55% and Vol. 53 No. 2 February 2017 Schedule With Abstracts 397

35%, respectively), p<0.0001 and p¼0.001, would Results. Eight common themes emerged: Activation/ recommend hospice for loved ones (88%) or them- empowerment, advocacy, education, building selves (88%) in intervention group compared to con- rapport/support, improving access, clarifying values trol (65% and 66% respectively), p¼0.0004 and and goals, screening for symptoms, and exploring 0.0005. self-care. Exemplars will be presented. Conclusion. A culturally tailored patient navigator Conclusion. PNs often helped the patients and their intervention can increase advance care planning and families in ways beyond the conceptualized scope of help patients align with a palliative approach in the intervention. PNs used advocacy, activation, educa- Latinos with advanced cancer. tion, and motivational interviewing to help address pa- Implications for research, policy or practice. An tient/family concerns. The relationships established effective, widely disseminated patient navigator inter- between PNs and patients/families helped reduce bar- vention has the potential to reduce cancer-related dis- riers to quality PC in both urban and rural settings. parities, improve PC for cancer patients, and improve Implications for research, policy or practice. An access to quality PC care in rural communities. opportunity exists to use a lay PN model to provide PC support and education to patients/families. Incorpo- Apoyo con Carino:~ A Qualitative Analysis of rating this model in PC work with other cultures has a Palliative Care Focused Patient Navigator chance to improve PC access to disparate populations. Visits for Latino Patients with Advanced Cancer (SA508C) Comparison of the Risk for Substance Abuse Regina Fink, PhD RN APN CHPN AOCN FAAN, Uni- in Heart Failure and Cancer Patient versity of Colorado, Aurora, CO. Stacy Fischer, MD, Populations Using the Opioid Risk Tool and University of Colorado Health Sciences Center, Urine Drug Screen (SA508D) Aurora, CO. Danielle Kline, MS, University of Colora- Gene Freeman, MD, Cone Health, Greensboro, do School of Medicine, Aurora, CO. Greensboro, NC. Joshua Barclay, MD MS MSC FACP, University of Virginia, Charlottesville, VA. Objectives Describe 3 key components of a patient navigator Objectives intervention to improve palliative care outcomes Describe risk factors for substance misuse. of Latinos with advanced cancer. Describe method for effective utilization of Identify 5 common roles of a lay patient navigator screening protocol for substance misuse in outpa- to improve palliative care outcomes. tient clinic setting. Original Research Background. A lay patient navi- Original Research Background. Opioid abuse has gator (PN) model was used to deliver a culturally reached epidemic levels. Palliative care commonly in- tailored intervention aimed at improving palliative cludes congestive heart failure (CHF) patients, yet lit- care (PC) outcomes for Latinos with advanced cancer tle is known about their substance abuse risk. at 3 urban and 5 rural cancer centers. Five PN-initiated Research Objectives. Characterize substance misuse home visits were delivered over three months to 112 risk in CHF patients using the Opioid Risk Tool patients assigned to the intervention arm of this (ORT). Compare substance misuse risk in CHF pa- RCT. While the PN visits addressed three PC domains tients to that of outpatient cancer patients. (advance care planning, pain/symptom management, Methods. University of Virginia Palliative Care sees and hospice care), each visit was grounded in core patients in oncology and CHF clinics. Charts from can- Latino values and responsive to patient/family needs. cer and CHF populations from respective clinics for Research Objectives. To explore and describe the the month of December 2015 were reviewed. Demo- content of PN visits with advanced cancer Latino pa- graphic variables, payer source, primary cancer, etiol- tients and their families. ogy of CHF (ischemic vs non-ischemic), ORT Methods. Three members of the research team re- variables, UDS results, and presence of opioid prescrip- viewed and analyzed field notes of four Latina PNs tions were recorded. Bivariate analysis compared can- comprising 499 visits to 112 patients. Based on our pre- cer versus CHF with demographic variables and risk vious work, codes were established a priori to identify for opioid diversion. Logistic regression examined different ways the PN might help patients/families. Us- the correlation between moderate to high ORT score ing Atlas.Ti, key words and comments from the field and cancer site, etiology of CHF, palliative diagnosis notes were classified into categories. Additional codes (cancer vs. CHF), insurance type, use of opioids, and were established during multiple readings of the field sex. notes and researcher team meetings. These codes Results. Charts of 271 patients were reviewed (202 were then grouped into common themes to expand cancer patients, 69 CHF). 80.69% of cancer patients our understanding of patient/family PC needs. were prescribed opiates versus only 20.29% of CHF 398 Schedule With Abstracts Vol. 53 No. 2 February 2017

patients (p<0.0001), but ORT scores were similar, with healthcare providers; the status of education and 39.11% of cancer patients scoring moderate to high research in the field; and the unique challenges risk versus 23.19% of CHF patients (p¼0.052). In lo- facing patients and providers. There will be time gistic regression, site of cancer, etiology of CHF, and allotted after each presentation to field questions palliative diagnosis were not associated with ORT and dialogue from the audience. Prepare to be risk, while opioid use (OR 3.86, CI ¼ 1.72 - 8.96) educated and inspired by these accomplished indi- and Medicaid insurance (OR 3.81, CI ¼ 2.023 e viduals who are leading and advancing the field of 7.172) were associated with higher scores. hospice and palliative medicine in their countries Conclusion. While fewer CHF patients are prescribed of origin. opiates, the risk of substance abuse was similar to cancer patients. Use of Medicaid was associated with higher The Importance of Medical-Legal ORT scores. Partnerships: Helping Children with Life- Implications for research, policy or practice. Almost limiting Illness with Do-Not-Attempt- one fourth of CHF patients were moderate to high risk Resuscitation Orders in Schools (SA512) for substance misuse. Screening rates are low in palliative Maureen Giacomazza, MA RN, C.S., Mott Children’s clinics nationwide. As providers expand into CHF popu- Hospital, University of Michigan, Ann Arbor, MI. De- lations, appropriate screening is essential for safe and bra Chopp, JD, University of Michigan Law School, effective treatment. Ann Arbor, MI. Kenneth Pituch, MD, University of Michigan, Ann Arbor, MI. Objectives Noone1pm Identify frequent contradictions between school policies and state laws which deny parents’ rights Critical Conversations: Opioids in Hospice to have DNAR wishes honored. and Palliative CareeBalancing Access and Discuss effective strategies to advocate for the de- Safety (SA510) livery of appropriate emergency plans for chil- dren with life-limiting illness at school. Identify effective emergency plans which can 1:15e2:15 pm lead to improved quality-assurance measures for children in their schools and their Concurrent Sessions community. Parents of children with life-limiting illness often reach a point where they recognize that aggressive The Practice of Palliative Medicine in d medical treatment will cause more harm than good, Developing Countries Part Three (SA511) and their goals of care shift to a focus on comfort. Eunice Omoyeni, MBBS Dip PallMed, University Col- In collaboration with their medical team, parents lege Hospital, Ibadan. NigeriaLee Ai Chong, MBBS, make a decision to implement a Do-Not-Attempt- MRCPCH, Grad Cert Pall Care, Hospis Malaysia, Kuala Resuscitation order for their child. Once parents Lumpur, Malaysia. Maria Isabel Cuervo Suarez, MD, decide to create a DNAR order for their child within Fundacion Valle de Lili, Santiago de Cali, Columbia. the hospital setting, they expect that the order will Objectives be honored and their child will be spared futile and Learn how physicians in specific countries pro- painful resuscitation attempts outside of the hospital vide palliative care to their patient populations setting as well. This is not always the case. Many school often with limited resources. districts across the nation will not honor a DNAR Understand specific cultural and political chal- declaration for a child in school. Medical-legal part- lenges to developing palliative care clinical, nerships can help. In this session, we will review pol- educational and research programs. icies in the state of Michigan as they pertain to Describe roles of different health care providers DNAR orders and will identify collaborative advocacy practicing palliative care and how they meet the strategies for palliative care professionals to challenge needs of their local populations. these policies in their own clinical practice Please join AAHPM’s International Scholars for a community. panel discussion. Each scholar will present for Methods. Literature and case review will be used as 10-15 minutes on the state of the practice of palli- the basis for discussion. We will describe successes, les- ative care in their home country, with an emphasis sons learned, and explore other potential avenues for on the roles of physicians, nurses, and other change. Vol. 53 No. 2 February 2017 Schedule With Abstracts 399

The Ever-Evolving Role of the Hospice improve PopH by impacting two of the three pillars Medical Director: Quality, Regulations, of the Institute for Health Improvement’s (IHI) Triple Narratives, Relatedness, and the Hospice Aimdimproving patient experience and reducing FormularydPart 2 of 2 (SA513) cost. The third pillar, improving the health of popula- Robert E. Crook, MD FACP, Mount Carmel Hospice tions, will be impacted by PC programs that under- and Palliative Care, Columbus, OH. Judi Lund Person, stand PopH and self-design using a population- MPH CHC, National Hospice and Palliative Care Or- focused approach. ganization, Alexandria, VA. Joan K. Harrold, MD How are programs to shift their thinking away from MPH FACP FAAHPM, Hospice & Community Care, program-focused growth toward cutting edge PopH- Lancaster, PA. focused growth? In this concurrent session, our team will present a new way forward for programs Objectives looking to grow. Using IHI’s Triple Aim as the Discuss disease-specific commonly-related condi- impetus for this new thinking, we will discuss old tions and the hospice provision of medications. and modern definitions of PopH and relate each of Discuss the current hospice regulatory environ- them to PC’s broad applicability to populations with ment and how it relates to the hospice provision serious illness. We will present historical growth pat- of medication for specific conditions. terns within PC and show that the focus has been Presentation 2 of 2: New and ever changing regulations on patient-level needs using workforce or leadership for hospices continue to challenge us to improve our driven designs that typically lack a PopH focus. After documentation, streamline our processes, and deter- explaining data-driven PopH assessment techniques mine relatedness and coverage of diagnoses and medi- like hotspotting and mapping, the Banner Health cations. Join us to understand best practice for experience creating a multi-state, integrated, stan- documenting CTIs as well as explore common issues dardized PC program focused on PopH will be thor- around determining diagnostic relatedness and hos- oughly explored and lessons learned during the pice provision of medications. This session will include process will be shared to help programs avoid com- an up-to-date report on current and proposed regula- mon mistakes. tions; the development and structure of a persuasive No longer can health systems care only for patients CTI; and tools to help your program to determine relat- who walk through their doors. This session will pro- edness of diagnoses and coverage of medications. vide a leading-edge, PopH approach to PC program Thinking Big: How You Can Develop a development to ensure PC programs can continue to Palliative Care Program at Population meet patients’ and communities’ needs. Health’s Leading Edge (SA514) Christopher Jones, MD FAAHPM, Main Line Palliative Care, Radnor, PA. Stacie Pinderhughes, MD, Banner Challenging the Paradigm of ‘‘The Lethal Health, Phoenix, AZ. Julie Lehn, PharmD, Banner Condition’’: The Case of Trisomy 13 and 18 Health, Phoenix, AZ. Arif Kamal, MD MHS MBA (SA515) FAAHPM, Duke Cancer Institute, Durham, NC. Katherine Nelson, MD, Hospital of Sick Children, Tor- Objectives onto, ON. Christopher A. Collura, MD, Mayo Clinic Articulate how Palliative Care (PC) is a solution to Children’s Center, Rochester, MN. Kevin Madden, Population Health needs. MD, MD Anderson Cancer Center, Houston, TX. Jor- Describe the varied historical drivers of PC pro- dan Miraglia, MS LISW-CP, Hands of Hope Hospice gram development. and Palliative Care, Columbia, SC. Utilizing the Banner Health experience as a Objectives guide, create a path forward within your institu- Discuss the evidence (and areas of uncertainty) tion to focus on PopH needs using the PC about survival and surgical interventions in tri- program. somy 13 and 18. Population Health (PopH), defined most broadly, in- Describe neonatal resuscitation, intensive care, cludes every health system, behavior, outcome, and and potential barriers to family-centered care person in the world. This definition can be so over- for neonates with life-threatening illness common whelming as to be useless. More narrowly defined in Trisomy 13 and 18. through a health system’s lens, PopH requires Compare and contrast the medical issues that knowing the system’s population and engineering face children with Trisomy 13 and 18 across their care models to optimize their health. As PC moves life span. from predominantly end-of-life care to upstream Demonstrate the need for psychosocial interven- care of the seriously ill, we are well positioned to tion specific to life limiting illness in neonates. 400 Schedule With Abstracts Vol. 53 No. 2 February 2017

How we describe diagnoses matter. Most palliative care Cardinale Smith, MD PhD MSCR, Icahn School of clinicians are exquisitely sensitive to this fact. However, Medicine at Mount Sinai, New York, NY. phrases like ‘‘lethal condition’’ remain in common Objectives d medical parlance and shape how all of us providers Describe and demonstrate a clinical coaching d and families alike conceptualize certain diseases. model for teaching primary palliative care skills. This session will explore the power of this phrase Illustrate how the clinical coaching model can be and how its use may influence our conversations used in different settings and with different types with families. and disciplines of learner, ranging from faculty to Trisomy 13 and 18 (T13/18) are relatively common medical students. genetic diagnoses. While most children die in the first Explore challenges of clinical coaching including year of life, emerging research suggests that longer- how to measure outcomes, find resources, and term survivors live well into childhood. These diagno- develop a program. ses have variable severity of illness across multiple or- With severe palliative care workforce shortages and gan systems, potentiating this prognostic uncertainty. growing needs of an aging population with serious Parents of patients with T13/18 often face medical de- illness, the demand for specialty level palliative care cision-making during multiple time points in the will greatly exceed availability within the current estab- child’s life, from prenatal birth planning to discus- lished models of palliative-care delivery. The solution sions regarding invasive interventions for the infant proposed here is, through clinical coaching, to teach or child. front-line clinicians how to provide primary palliative Many families choose to focus on the baby’s comfort care. The goal of clinical coaching is to use expert at birth through perinatal hospice services while teaching and communication practices to make it others advocate for surgical interventions. Disagree- easier for clinicians of all levels to ask for and receive ments between health care providers and parents help. about the child’s best interest are common. Pallia- In this session, we will describe a basic model of clin- tive care and hospice clinicians are often asked to ical coaching and illustrate how this model can be provide expertise in navigating goals of care, symp- used with individual learners in the workshop or clin- tom management, and psychosocial support. Given ical setting. We will then describe three different appli- this consultative role, a strong knowledge base of cations of clinical coaching currently used at 2 the current evidence in care for these patients is different institutions across multiple disciplines and needed. specialties: (1) family meeting communication coach- This session will be framed across two epochs in the ing through two methods, i.e. direct observation of child’s life: the perinatal-to-infant period, and the palliative care fellow trainees and an easy-access office longer-term survivor period (childhood-to-adoles- hours approach for attendings; (2) a structured cence), and it will describe the latest population- communication coaching intervention with oncolo- based research for each phase. The session will gists in the outpatient setting; and (3) a service-deliv- focus on interdisciplinary considerations, including ery model that offers ‘‘coaching consultation’’ to psychosocial challenges for families, as well as re- inpatient clinicians. Finally, we will discuss challenges viewing supportive resources. It will explore shared of implementing clinical coaching including how to decision-making including common medical and find resources, develop a program for referring clini- surgical considerations. Discussion about both cians, and measure outcomes. time periods will contain symptom-management guidance during hospitalizations and at end-of-life. Moral Injury: Invisible Wounds of Combat The session will include perspectives from pediatrics, (SA517) epidemiology, neonatology, intensive care, palliative John Franklin, MD HMDC, Ralph H. Johnson VA care, and hospice. Medical Center, Charleston, SC. John Painter, PhD MDiv, Ralph H. Johnson VA Medical Center, Charleston, SC. Kelly Cooke, DO, ProHealth Care, See One, Do One, Coach One: How Clinical Waukesha, WI. John Schluep Doctor of Ministry, First Coaching Can Help Trainees and Colleagues Congregational Church of Tallmadge, Tallmadge, Just When They Need It with Just What They OH. Need (SA516) Objectives Juliet Jacobsen, MD, Massachusetts General Hospital, Define and understand Moral Injury as defined Boston, MA. Elizabeth Lindenberger, MD, Icahn in recent scholarship and how it differs from School of Medicine at Mount Sinai, New York, NY. PTSD. Vol. 53 No. 2 February 2017 Schedule With Abstracts 401

Discuss examples of moral injury using actual vet- York, NY. Peiyi Lin, EdD, Teachers College, Columbia eran stories. University, New York, NY. Rosio Ortega, BS, Hospice of Understand the impact of moral injury upon vet- the Valley, Phoenix, AZ. erans at the end of life. Objectives Various definitions of moral injury exist. Jonathan Identify an opportunity to initiate and advance Shay describes it as ‘‘a betrayal of what’s right, by some- excellent practice of palliative care for dementia one who holds legitimate authority, in a high stakes sit- with public and private health care insurers in uation.’’ Brett Litz defines moral injury as our changing health care environment. ‘‘perpetrating, failing to prevent, bearing witness to, Assess the symptoms of a patient with dementia or learning about acts that transgress deeply held and recommend a behavioral and medication moral beliefs and expectations.’’ management care plan based upon best available Moral injury as an entity has only recently been recog- evidence to maximize comfort and quality of life. nized and efforts to address it begun. At the present Original Research Background. The Palliative Care time, it is not accepted as a diagnosis by the Depart- for Dementia (PCD) model supports caregivers for per- ment of Defense or the Veterans Administration. sons with early, mid-stage, or advanced dementia who Moral Injury related to combat is a concept as old as are not yet eligible for hospice. Literature review iso- war itself. It is referred to in ancient Greek literature lated critical components for program design. Program and throughout history. When the noble cause for components include Dementia Educator home visits which one volunteered is compromised a moral injury twice a month for the first month and then monthly occurs. Several centers across the country are now con- for a minimum of three months; 24/7 triage nurse ducting research about moral injury and its treatment. phone support for challenging behaviors; and geriatri- Spiritual and faith communities have taken a signifi- cian phone consultations. cant role in addressing and healing moral injury. Research Objectives. Outcomes of moral injury include: shame, guilt, anger, isolation, desperation, despair, demoralization, 1. Develop a cost-effective model to reduce care self-handicapping behaviors and self-harming behav- giver stress and improve quality of life for persons iors including suicidality. Unresolved moral injury with dementia and caregivers. can complicate the care of Veterans with serious, life 2. Demonstrate that the model saves health care limiting, or life-threatening illnesses and have serious costs and thus can be adopted by public and effects on their quality of life. Therefore, it is very private health care insurers. Methods. important that palliative care providers caring for Vet- 240 managed care Medicaid members with a erans have a good understanding of the complexities diagnosis of dementia were determined by the plans to of moral injury. be at a nursing home level of care but resided in private This concurrent session will review the definition of or group homes. Each pair of referrals was randomized moral injury and how it differs from PTSD. Using stor- into two groups. 120 members received the PCD model; ies of combat Veterans, role play and short video pre- 120membersreceivedusualcare.Allhealthcarecosts sentations, causes of moral injury will be discussed. for both groups were tracked for one year. Both groups The effects of moral injury on the care of Veterans completed satisfaction surveys after three months, and in general and Veterans dealing with serious, life PCD members completed Zarit Burden Interviews limiting, or life-threatening illnesses in particular will (ZBI) on admission and after three months. be illustrated. This multidisciplinary panel will discuss Results. Preliminary results showed a savings of $398/ current treatment options both in the mental health member/month, $123 beyond the $275/member/ and chaplaincy fields. month cost of the program. Satisfaction surveys indicated 88% satisfaction, with no difference between groups. ZBI Paper Session showed significant reduction in stress (p<.05). Conclusion. The PCD program reduced stress and saved costs when compared with a control group. Palliative Care for Dementia: A Randomized Implications for research, policy, or pra- Controlled Study of a Replicable and ctice. Satisfaction, burden reduction, and cost savings Financially Viable Model for Organizations data convinced the Medicaid plan to contract to Providing Caregiver Support (SA518A) pay for the program in the coming year, and is a viable Gillian Hamilton, MD PhD, Hospice of the Valley, option for other insurance plans nationally. The pro- Phoenix, AZ. Maribeth Gallagher, DNP FAAN, Hos- gram, which combines social and medical intervention pice of the Valley, Phoenix, AZ. Kristen Pierson, BA, in a cost-effective manner, can be easily duplicated. Hospice of the Valley, Phoenix, AZ. Susan Lowes, Methods and materials for program replication will be PhD, Teachers College, Columbia University, New provided. 402 Schedule With Abstracts Vol. 53 No. 2 February 2017

Who Should Discuss Advance Care Conclusion. Seriously ill, hospitalized non-oncology Planning? A Survey of Preferences Among patients prefer to have ACP conversations with outpa- Hospitalized Patients with Serious Illness tient physicians, most commonly their PCP. Longer (SA518B) and stronger relationships are associated with PCP Jennifer Faig, MD, Beth Israel Deaconess Medical Cen- preference. ter, Boston, MA. Mary Buss, MD, Beth Israel Deaconess Implications for research, policy or practice. This Medical Center, Boston, MA. Lauge Sokol-Hessner, study provides the medical community with the MD, Beth Israel Deaconess Medical Center, Boston, perspective of seriously ill, hospitalized patients MA. Elizabeth Targan, MD, Beth Israel Deaconess regarding ACP. The results should encourage PCPs Medical Center, Boston, MA. Kenneth Mukamal, and outpatient specialists to initiate ACP. MD, Beth Israel Deaconess Med Center, Boston, MA. 1. Lamont 2000. J Palliative Med. Objectives Define a population of non-oncology patients Advanced Dementia: The Black and White with serious illness using disease specific criteria. of Mechanical Ventilation for Pneumonia Identify with whom non-oncology hospitalized pa- and Septicemia (SA518C) tients with serious illness prefer to have advance Joan Teno, MD MS, University of Washington, Seattle, care planning conversations. WA. Rashmi Sharma, MD MHS, University of Washing- Apply this data to educate outpatient physicians ton, Seattle, WA. J Randall Curtis, MD MPH, Univer- about the importance of advance care planning sity of Washington, Seattle, WA. Nita Khandelwal, conversations. MD MS, Harborview Medical Center, Seattle, WA. Original Research Background. Advance care plan- Ruth Engelberg, PhD, University of Washington, Seat- ning (ACP) is the process whereby patients articulate tle, WA. Vincent Mor, PhD, Brown University, Provi- their preferences regarding medical care at the end dence, RI. Pedro Gozalo, PhD, Brown University of life. For the seriously ill, ACP is a priority; however School of Public Health, Providence, RI. David Melt- it is unclear with which provider patients prefer to zer, MD, PhD, University of Chicago, Chicago, IL. have those conversations. Objectives Research Objectives. 1.To determine with which Explore the natural history of mechanical ventila- provider seriously ill, hospitalized, non-oncology pa- tion in pneumonia in hospitalized persons with tients prefer to have ACP conversations. 2. To identify advanced dementia. factors associated with a patient’s provider preference. Understand the variation of increasing use of me- Methods. Investigators developed a survey to assess chanical ventilation in pneumonia/septicemia in patients’ preferences, adapting items from a prior in- persons with advance dementia. strument.1 In conjunction with disease experts, inves- Original Research Background. Over the past tigators developed criteria to define ‘seriously ill’ decade, feeding tube use in nursing home (NH) resi- inpatients with common non-oncologic diseases dents with advanced dementia has declined by 50% (CHF, ESRD, COPD, and cirrhosis). Patients were even among Blacks. Has a similar reduction occurred eligible if they met ‘seriously ill’ criteria and/or one in other invasive interventions such as mechanical year mortality was high as determined by the ‘Surprise ventilation? Question.’ Patients on the medicine inpatient services Research Objectives. Examine the use of mechani- at an academic hospital were surveyed. cal ventilation in Black and White NH residents with Results. A total of 54 of 69 approached patients con- advanced dementia who were hospitalized for pneu- sented to participate. The majority (94%) (95% CI monia or septicemia. 89-100%) thought ACP was important; a minority Methods. Retrospective cohort study of Medicare (38%) [95% CI 25-53%] discussed ACP with a doctor Beneficiaries with advanced dementia hospitalized be- before hospitalization; 14% [95% CI 6-26%] had an tween 2000 and 2013 that examined the use of me- ACPconversationwithadoctorduringtheindex chanical ventilation. Two multivariate logistic hospitalization. Most (85%) [95% CI 72-93%] prefer regression models examined the association between to discuss ACP with an outpatient provider (66% race and the likelihood of receiving mechanical venti- primary care physician (PCP), 19% outpatient lation, controlling for patients’ demographics, func- specialist). Age, gender, frequency of outpatient visits tion, and comorbidities. A fixed effect model and inpatient hospitalizations were not associated with examined the association of race within a hospital, physician preference. Longer duration and increased while the second model used robust clustering to strength of the relationship were associated with pre- examine the overall association of race. ference for PCP (p¼0.08 and p ¼ <0.0001, Results. Between 2000 and 2013, 211,124 advanced respectively). dementia patients were hospitalized for pneumonia Vol. 53 No. 2 February 2017 Schedule With Abstracts 403

or septicemia. During these hospitalizations, Whites’ prognostic models, possibly identify other clinical use of mechanical ventilation increased from 3.8% criteria that may accurately predict prognosis in pa- to 10.4% and Blacks’ use increased from 7.6% to tients with Alzheimer’s Dementia. 17.1%. Among those ventilated, one-year mortality re- Methods. A detailed analysis of admission profiles mained high with 83.9% of Whites vs. 83.7% of Blacks of patients admitted to SH&PC in 2013 under dying in 2012. Compared to Whites, Blacks had a high- ICD - 9 code 331 (Alzheimer’s Dementia). All pa- er odds of receiving mechanical ventilation in the tients studied met the current hospice prognostic fixed effect (within hospital) model (AOR 1.33; 95% criteria. CI 1.27-1.38) and in the model with robust clustering Results. 221 patients with Alzheimer’s dementia were AOR 1.77; 95% 1.63 -1.91). identified for analysis. Of these patients, 29% survived Conclusion. Unlike feeding tube use, mechanical longer than six months (mirroring national data) and ventilation use among advanced dementia patients 71% died within six months. Patients surviving longer has substantially increased, with Blacks having a larger than 6 months had mean MMI of 7.7 and those surviv- increase compared to Whites that is based, in part, on ing less than six months had a mean MMI of 9.5 (Risk the hospitals where Blacks receive care. estimates of death within 6 M, 40.4% and 57% respec- Implications for research, policy or pra- tively). Ethnicity was a significant factor in predicting 6 ctice. Reductions in feeding tube use in advanced M prognosis; a much lower percentage of African dementia suggests change is possible and our findings American patients lived longer than 6 M as compared suggest that over-utilization of mechanical ventilation with other ethnic groups and almost 60% of them should be the next target. Efforts are needed to ensure resided in NHs. that advanced dementia patients receive care consistent Conclusion. Predicting mortality using current prog- with their informed preferences and likely outcomes of nostic guidelines, fails in approximately 30% Alz- care. heimer’s patients, indicating a need for additional work in this area Implications for research, policy or pra- Predicting a Six-Month Prognosis in Patients ctice. More research into identifying specific, with Alzheimer’s Dementia: A Shot in the sensitive prognostic models for Alzheimer’s pa- Dark? (SA518D) tients. Additionally; we could make the case for al- Sonali Wilborn, MBBS MD MBA, Seasons Hospice & lowing for a longer length of stay on hospice Palliative Care, Madison Heights, MI. Navdeep (maybe 1 year) for patients with a dementia Grewal, MD, Seasons Hospice and Palliative Care, diagnosis. Madison Heights, MI. Objectives Retrospectively analyze our patient data to eval- uate the accuracy of the current prognostic indi- 2:30e3:30 pm cators used to predict hospice eligibility for patients with Alzheimer’s Dementia. Concurrent Sessions Evaluate for the presence of other clinical criteria that may be used to predict a 6 month prognosis in patients with advanced Alzheimer’s Using QI Methodology to Standardize Dementia. Education for Families Considering Original Research Background. Alzheimer’s De- Tracheostomy Placement and Permanent mentia is the second most common non cancer hos- Mechanical Ventilation for Their Children: pice diagnosis (12.5%). With the increased burden An Attempt at Full Disclosure (SA520) of caring for an aging population there is a need to Rachel Thienprayoon, MD, Cincinnati Children’s accurately evaluate the prognosis of patients with Hospital Medical Center, Cincinnati, OH. Lesley Alzheimer’s Dementia. Predicting mortality, assessing Doughty, MD, Cincinnati Children’s Hospital Medical prognosis is a challenging task for physicians and hos- Center, Cincinnati, OH. Hemant Sawnani, MD, Cin- pice organizations. Nationally, 25% of patients on cinnati Children’s Hospital Medical Center, Cincin- hospice with a diagnosis of Dementia had > 6M nati, OH. Mark Meyer, MD, Cincinnati Children’s LOS. Hospice organizations constantly struggle to Hospital Medical Center, Cincinnati, OH. Dan Ben- follow strict Medicare hospice guidelines while re- scoter, DO, Cincinnati Children’s Hospital Medical maining sensitive to the clinical needs of these Center, Cincinnati, OH. Marsha Blount, MSN CNP patients. APRN, Cincinnati Children’s Hospital, Cincinnati, Research Objectives. Retrospectively analyze our OH. Catherine Hart, MD, Cincinnati Children’s Hos- patient data to evaluate the accuracy of current pital Medical Center, Cincinnati, OH. Lori Herbst, 404 Schedule With Abstracts Vol. 53 No. 2 February 2017

MD, Cincinnati Children’s Hospital Medical Center, script to utilize in family meetings, and educating Cincinnati, OH key stakeholders in the institution regarding the pro- cess. The smart aim of this project is to increase the Objectives use of a standardized communication format for Attendees will understand the long-term implica- eligible patients/families considering tracheostomy tions and decision-making complexities sur- placement from 0% to 100% by April 1, 2017. rounding tracheostomy placement and permanent mechanical ventilation, including Primary Pediatric Palliative caregiver burden of tracheostomy care and poten- d tial for limited community resources. Care Teaching and Learning from the Attendees will be able to describe the quality Bedside to the Community (SA521) improvement methodology used to standardize Kathy Perko, MS RN, Doernbecher Children’s Hospi- communication around this decision in our tal at Oregon Health & Science University, Portland, institution. OR. Deborah Lafond, DNP NP PNP CHPPN CPNP Attendees will be able to articulate novel ap- CPON, Children’s National Medical Center, Washing- proaches to use in their own institutions to ton, DC. improve communication around complex deci- Objectives sion making for families. Identify teaching opportunities and curriculum The decision to place a tracheostomy tube in a child to provide primary palliative care to physicians, who will be ventilator-dependent for the duration of advanced practice nurses and bedside staff. her life is complex. Family values, goals of care, family Provide a framework for providing and support- and community resources, homecare nursing, and ing primary palliative care in partnership with risks and benefits of the procedure itself should be community based adult hospices. taken into account when counseling a family facing Over the past decades, hospital based pediatric palliative this decision. Frequently, these decisions are made care programs have significantly increased, however, during an admission for acute respiratory failure in palliative care referrals are still often delayed and many which the child requires intubation and mechanical children still die in the hospital. Primary palliative care ventilation in the intensive care unit, and extubation education increases the ability for bedside clinicians as has become impossible. Therefore families may well as advanced practice nurses and physicians to advo- approach this complex decision alongside providers cate earlier for referrals and educates our adult hospice who do not have continuity with the child or a broader colleagues to allow more children to die with hospice appreciation of the family’s values and goals of care. support. The approach to explaining this choice, and recom- Innovative models are needed to improve access to mendations to guide the family, may differ based on care and continuity across the spectrum of services, the physician leading the conversation. While such as well as supporting bedside clinicians. Evidence providers may discuss the risks and benefits of the pro- shows palliative care improves patient and family satis- cedure and the impact on the child’s immediate faction, symptom control, and QOL, eases burdens, future, the larger context including long-term implica- and decreases health care utilization. Primary pallia- tions on the child and family may not be thoroughly tive care provided by bedside clinicians improves ac- explained and explored. cess to palliative care for children and families while Therefore, our institution has sought to utilize quality decreasing moral distress for clinicians and improving improvement methodology to standardize communi- palliative care clinical skills. cation surrounding the decision to place a tracheos- Professional education and development in palliative tomy tube in a child who will likely require lifelong care is mandated in the 2014 IOM report. Other IOM mechanical ventilation. A ‘‘Trach/Vent Consult’’ mandates addressed by this model include: Delivery of team was created including providers from the inten- Person-Centered, Family-Centered Care through provi- sive care unit, palliative care, otolaryngology, and pul- sion of timely, seamless, high-quality, integrated, child monology. Using a failure mode events analysis, and family-centered primary palliative care services aug- potential interventions for improvement were identi- menting the tertiary palliative care team and Clinician- fied: defining and educating the consult team, Patient Communication and Advanced Care Planning defining eligible patients/families, establishing a clear through development of an enhanced communication process for providers to consult the team, defining a skill set for the bedside to clarify goals of care and Vol. 53 No. 2 February 2017 Schedule With Abstracts 405

continue advance care planning discussions started by and practices from four pioneering home-based pallia- the primary medical team and/or tertiary palliative tive care programs providing services to seriously ill pa- care team. tients in a variety of living situationsdincluding their Most communities do not have access to a pediatric homes, assisted living residences, skilled nursing facil- hospice. A program to integrate primary palliative ities, and homeless shelters. At the forefront of commu- care education and support through adult community nity-based palliative care, these programs are leaders in hospices for pediatric patients will be presented. Dis- working with payers and in providing innovative, cost- cussion will include how education is provided, access effective approaches to providing quality home-based to the tertiary palliative care program and successes palliative care. They represent a variety of patient popu- and pitfalls. Using case studies, two programs will be lations, geographic settings, payment models, and orga- highlighted, the PANDA Palliative Care Team at Chil- nizational homes: a large hospice and palliative care dren’s National in Washington DC and Bridges at organization; a large home health and hospice organi- Doernbecher Children’s Hospital in Portland, OR. zation; an integrated multispecialty clinician group; and a health care system. Program leaders will share Diverse Models of Home-Based Palliative how they aligned their programs with the needs and pri- Care: Key Principles from Four Programs for orities of patients, families, community partners, and Impact on Quality and Cost (SA522) program stakeholders, as well as key principles and chal- lenges and opportunities encountered. An interactive Diane Meier, MD FACP FAAHPM, Icahn School of Med- Q & A session will follow. icine at Mount Sinai, New York, NY. Richelle Nugent Hooper, MBA MSN FNP-BC ACHPN, Four Seasons, Flat Rock, NC. Dana Lustbader, MD, ProHEALTH, Lake Success, NY. Robert Parker, DNP RN CENP Caring for Our OwndHow An Employee CHPN, Interim Healthcare, Lockhart, TX. Donna Ste- Health Incentive Plan Can Encourage vens, BS, Lehigh Valley Hospital, Allentown, PA. Advance Care Planning (SA523) Objectives Ira Byock, MD FAAHPM, Providence Health & Ser- Describe the role of home-based palliative care in vices, Torrance, CA. Matthew Gonzales, MD, Institute the continuum of palliative care programs. for Human Caring, Torrance, CA. Describe the characteristics of diverse successful Objectives home-based palliative care models. Demonstrate ways that advance care planning Explain the challenges and opportunities of avail- promotes a healthcare organization’s mission, able home-based palliative care models in order vision, and core values. to determine which characteristics best align Recognize traditional purposes of employee with your community. health incentive plans and how a healthcare com- Not so long ago palliative care was available only pany can engage employees in advance care plan- through the Medicare hospice benefit for the termi- ning as a means of promoting healthy behaviors nally ill. Now, hospital palliative care is a routine ser- for the company’s staff as well as the patient pop- vice, especially in larger hospitals that serve the ulation it serves. sickest and most complex patients. Yet, we are far Identify key operational components of the Prov- from securing relative access to palliative care for idence advance care planning health incentive our nation’s seriously ill patients and their families option and how this option was received by em- because the great majority of them are neither dying ployees and their insured family members. nor in the hospital. In order to ensure access to palli- America’s employer-based approach to health insur- ative care where people need it, we must help commu- ance strengthens companies’ stake in their em- nities build palliative care services that go to the ployees’ well-being. Corporate health incentive patient and their family where they live. plans have traditionally focused on reducing risks Home-based palliative care is the future of quality med- associated with physical illness, through activities ical care for the sickest and costliest patients and their related to smoking cessation, dietary modification, families. Several home-based palliative care programs increasing exercise, and monitoring BMI. For across the country are delivering this service to their pa- healthcare companies, such incentive plans carry tients; they serve as examples for others who want to an additional advantage of encouraging employees implement this critical service for seriously ill patients. to model the healthy behaviors that the corporation Panelists in this session will share replicable principles seeks to promote. 406 Schedule With Abstracts Vol. 53 No. 2 February 2017

Providence Health & Services is a large (35 hospitals, five growing number of palliative care clinics and mov- state) healthcare system that is committed to employee ing palliative care ‘‘upstream’’ clinicians are facing health and seeks to exemplify goal-aligned care. patients who have non-malignant pain associated The Institute for Human Caring proposeddand with their life-limiting illness. Growing evidence ex- senior leadership approveddan advance care plan- ists that long term opioid therapy may not be bene- ning (ACP) activity as a 2016 health incentive option. ficial in non-cancer pain. This coupled with an This is one part of a multifaceted plan to establish increasing regulatory environment is leading clini- goal-aligned care as a quality standard across Provi- cians to consider opioid tapering as an opioid man- dence, and make goals of care conversations a com- agement strategy when they encounter patients mon expectation of clinicians, patients and families where the risk benefit ratio may be unfavorable. alike. These may be patients who experience: 1.) lack of The Providence 2016 health incentive plan offered benefit (pain relief/functional improvement) insured employees and their covered family members despite repeated opioid escalation; 2) severe adverse the opportunity to view a brief (4 min) online video effects despite opioid rotation; and 3.) resolution of regarding ACP, complete 8 reflective questions about their disease process and 4.) exhibit evidence of sus- their own beliefs about ACP, and decide what action pected diversion, addiction or chemical coping or to take as a result of reviewing their ACP. A traditional opioid induced hyperalgesia. Surprisingly, current risk reduction activity was also available. guidelines do little to help clinicians with the pro- Over 51,000 individuals (91% of participating employees cess of opioid tapering. The goal of this session be and spouses) chose the ACP incentive option and over to allow attendees to gain confidence in opioid 80% rated the experience as helpful or very helpful. tapering. The session will be presented by a panel We examine how this health incentive plan fits within of pharmacists and palliative care clinicians. The ses- a multicomponent, non-incremental change strategy sion will focus on: 1.) Identifying the patient with an aimed at making goal-aligned, whole person care the adverse risk benefit for opioid use. 2.) Identifying new normal care. We present the components of this optimal regimens for opioid tapering. 3.) Learning ‘‘health journey’’ including marketing materials and how to identify and treat withdrawal symptoms and videos, and the key results, including participant provide taper support. 4.) Learning how to identify feedback. and treat withdrawal symptoms and provide taper Early evidence suggests that this health incentive plan support. 5.) Identifying the optimal agents to use is helping to drive cultural change consistent with in the tapering process. 5.) Identifying other re- organizational core values and strategic priorities. sources to support patients during the tapering pro- cess. 6.) Identifying risk mitigation strategies to Hey, Doc, Can We Cut Down on the Pain protect physicians during this process. Pills? Current Status of Opioid Tapering Guidelines and How to Do It (SA525) Research 101: A Practical Introduction to Eric Prommer, MD HMDC FAAHPM, Greater Los An- Understanding, Evaluating, and Applying geles Healthcare, Los Angeles, CA. Mary Lynn Palliative Care Research to Your Clinical McPherson, PharmD MA BCPS CPE, University of Practice (SA526) Maryland School of Pharmacy, Baltimore, MD. Ka- Dio Kavalieratos, PhD, University of Pittsburgh, Pitts- thryn Walker, PharmD BCPS CPE, Medstar Health, burgh, PA. Katherine Ornstein, MPH PhD, Icahn University of Maryland School of Pharmacy, Balti- School of Medicine at Mount Sinai, New York, NY. more, MD. Mellar Davis, MD FCCP FAAHPM, Geising- Marie Bakitas, DNSc CRNP ACHPN, University of er Medical Center, Danville, PA. Alabama at Birmingham, Birmingham, AL. Robert Objectives Arnold, MD FAAHPM, University of Pittsburgh, Learn how to safely taper patients who are on Pittsburgh, PA. chronic opioids. Objectives Learn how to manage symptoms during opioid Identify the rationale, strengths, weaknesses, and tapering. types of palliative care research questions that Identify resources for patient support during can be addressed by clinical trials, existing data tapering. analysis, and qualitative methods. Current guidelines for opioid therapy focus on how Discuss strategies for evaluating the quality of to safely and effectively prescribe opioids. With the published research, as well as for leveraging Vol. 53 No. 2 February 2017 Schedule With Abstracts 407

research to inform clinical practice in hospice Durham, NC. Thomas LeBlanc, MD MA, Duke Cancer and palliative care. Institute, Durham, NC. As hospice and palliative care continues to mature Objectives and expand, so does the evidence base supporting Explain 5 challenges experienced by patients with our discipline. Understanding how to interpret AML. research is an important skill for all clinicians, yet Describe 5 ways that early palliative care could keeping up with the state-of-the-science in research positively impact care for patients with AML. methodology can be daunting. In this session, we Original Research Background. Patients with acute will demystify three methodologies commonly used leukemias likely have unmet palliative care needs, yet in hospice and palliative care research: clinical tri- little is known about the specific challenges they als, existing (aka secondary) data analysis, and qual- face, particularly during active treatment. Early con- itative methods. All participants, regardless of current palliative care with standard oncology care fluency in research, will benefit from attending could help meet patients’ needs regarding symptom this session. management, social support, prognostic understand- Our multidisciplinary, multi-institutional panel of ing, psychological distress, and care goals. palliative care researchers and clinician-researchers Research Objectives. We examined acute myeloid will use case-based approaches to explain each meth- leukemia (AML) patients’ expressed challenges, sup- odology, its strengths and weaknesses, considerations port sources, and mortality perceptions after intensive of using each method within the idiosyncrasies of induction chemotherapy. We aimed to understand op- hospice and palliative care, as well as the strategies portunities for palliative care interventions for AML that experts use to assess research quality. Dr. Orn- patients. stein, an epidemiologist, will discuss how quantitative Methods. This was a qualitative study of AML pa- data can and cannot be used to explore associations tients with high-risk disease at Duke University Hos- or to establish causality, touching upon concepts pital, Durham, NC. Multiple coders used descriptive such as confounding and propensity score matching. content analysis to identify common and recurrent Dr. Bakitas, a nurse-researcher, will explain the con- themes. ceptual underpinnings of clinical trials, as well as Results. We analyzed interview transcripts of 22 patients. common pitfalls in palliative care trials and their im- Sample demographics included: 10 (45.5%) females, 12 plications. Dr. Kavalieratos, a health services (54.5%) males, mean age ¼ 62 (SD 10.9), 19 (86.4%) researcher, will provide an overview of qualitative de- non-Hispanic white, and 3 (13.6%) non-white/non-His- signs often seen in the palliative care literature, illus- panic. All had high-risk disease, either by age, relapse sta- trating their utility in both research and quality tus, or molecular markers. Patients identified challenges improvement. Lastly, Dr. Arnold will draw from his in 5 key domains: physical symptoms, psychological issues, experiences as a clinician-administrator to provide care coordination, uncertainty, and end-of-life care. Spe- examples of how to effectively apply findings from cific challenges included feelings of helplessness/hope- each type of study to clinical practice. lessness, activity restriction, fatigue, fevers, caregiver By the end of this session, participants will have a prac- stress, geographic distance to care, and confusion about tical grasp of clinical research concepts leaving them next steps in treatment/non-treatment. Sources of sup- better equipped to interpret and translate research ports included hope, resilience, families’/friends’ devo- into patient care. Participants are encouraged to tion, caregivers, scripture, and positive attitude. come ready with questions to be discussed in a moder- Interviewees reported relying on these supports to nego- ated question-and-answer session. tiate physical distress, psychological distress, and prog- nostic uncertainty. Perceptions related to mortality Paper Session included death/dying acceptance, processes of saying goodbye to loved ones, and outlook incongruent with prognosis. Interviewees frequently reported poor Acute Leukemia Patients’ Unmet Needs: communication/coordination by their care team, Qualitative Findings and Suggested including treatment plan uncertainty. Opportunities for Early Palliative Care Conclusion. AML patients face substantial challenges (SA527A) regarding symptoms, psychological distress, care coordi- Nathan Boucher, DPH MPA MS PA, Durham VAMC nation, uncertainty, and end-of-life care. These chal- GRECC/Duke University, Durham, NC. Kimberly lenges signal unmet palliative care needs in high-risk Johnson, MD MHS, Duke University Medical Center, AML patients. 408 Schedule With Abstracts Vol. 53 No. 2 February 2017

Implications for research, policy, or pra- moderate or severe symptom, most commonly ctice. These findings highlight opportunities to anorexia, decreased wellbeing, and fatigue. Large mi- develop targeted palliative care interventions address- norities reported psychosocial challenges and moder- ing symptom management, social support, prognostic ate or greater distress. Despite expressing satisfaction understanding, psychological distress, and communi- with the information received about their cancer, cation in AML patients. 62% of patients believed that they had at least a 50% chance of being cured of cancer. Conclusion. Physical symptoms, psychosocial con- Symptom Burden in Patients Initiating cerns and poor prognostic awareness are common Treatment for Metastatic Colorectal Cancer among patients with mCRC. Based on these data, we (SA527B) designed and implemented an integrated PC program Laura Cantino, MD, Icahn School of Medicine.at that includes weekly multidisciplinary meetings with Mount. Sinai, New York, NY. Carling Ursem, MD, Uni- oncology and PC providers, and proactive PC visits versity of California San Francisco, San Francisco, CA. from the time of diagnosis, which are coordinated Christine Ritchie, MD FAAHPM, University of Califor- within the oncology clinic. nia San Francisco, San Francisco, CA. Michael Rabow, Implications for research, policy or pra- MD FAAHPM, University of California San Francisco, ctice. Patients have significant PC needs close to the San Francisco, CA. Chloe Atreya, MD PhD, University time of diagnosis of mCRC, supporting integration of California San Francisco, San Francisco, CA. Kara of PC services into their routine cancer care. Bischoff, MD, University of California San Francisco, San Francisco, CA. Objectives Adherence to the American Society of Describe the most prevalent symptoms and con- Radiation Oncology Choosing Wisely cerns of patients with metastatic colorectal cancer. Campaign Recommendations for Treatment Summarize key features of a model to integrate of Bone Metastasis: Analysis of Medicare outpatient palliative care into usual oncologic Data at 12 Centers in the Southeast US care for metastatic colorectal cancer. (SA527C) Original Research Background. Current NCCN Audrey Wallace University of Alabama at Birmingham, guidelines recommend early integration of palliative Birmingham, AL. Courtney Williams, MPH, University care (PC) into routine cancer care, particularly for pa- of Alabama at Birmingham, Birmingham, AL. Eliza- tients with metastatic solid tumors. However, no study beth Kvale, MD, University of Alabama at Birmingham has yet focused on PC needs specific to patients with Center for Palliative and Supportive, Birmingham, AL. metastatic colorectal cancer (mCRC). Bradford Jackson, PhD, University of Alabama at Bir- Research Objectives:. mingham, Birmingham, AL. Maria Pisu, PhD, Univer- 1. To characterize PC needs of patients with mCRC. sity of Alabama at Birmingham, Birmingham, AL. 2. To use findings to inform the design and Edward Partridge, MD, University of Alabama at Bir- implementation of an integrated PC program. mingham, Birmingham, AL. Gabrielle Rocque, MD, Methods. We are conducting a pre-post prospective University of Alabama at Birmingham, Birmingham, cohort study of integrated PC for patients with AL. mCRC. We enrolled patients within 90 days of diag- Objectives nosis or of establishing care for mCRC. Patients were Understand adherence to Choosing Wisely guide- surveyed regarding symptoms, quality of life, psycho- lines from a radiation oncology perspective. social concerns, functional status and understanding Appreciate the impact of patient, practitioner, of prognosis. During the pre-implementation phase, and system on choice of duration of treatment. described here, patients received usual oncologic Original Research Background. The American So- care, with referral to outpatient PC available at oncol- ciety of Therapeutic Radiation Oncology (ASTRO) ogist discretion. Choosing Wisely (CW) campaign recommends avoid- Results. The 29 patients in the pre-implementation ance of extended fractionation (>10 treatments) for phase were enrolled a median of 48 days from the palliation of bone metastasis with radiation therapy time of diagnosis of mCRC. Median age is 60 (range (RT). 22-86), 34% are women, 38% identified as non-Cauca- Research Objectives. The purpose of this study is to sian, and 28% have limited English proficiency. Sev- analyze palliative fractionation schemes in a cohort of enty-two percent of patients reported at least 1 Medicare patients. Vol. 53 No. 2 February 2017 Schedule With Abstracts 409

Methods. Data were for Medicare patients > 65 with Recognize the value of and describe the possible bone metastasis diagnosis from 12 cancer community outcomes of integration of palliative care into networks affiliated with an academic center in Alaba- the routine oncology care of adolescent and ma, Mississippi, Georgia, Tennessee, and Florida. young adult oncology patients. Stage IV cancer patients treated with radiation for Develop prospective ways to evaluate the role and bone metastasis from Quarter 1, 2012 to Quarter 1, effect of palliative care involvement in adolescent 2015 were eligible and identified using ICD- and young adult oncology patients 9(198.5) and CPT/HCPCS codes. Adherence was Original Research Background. Adolescent and measured by treatment duration # 14 vs >14 calen- young adult oncology (AYAO) patients often receive dar days. intensive care and experience significant symptoms Results. 2194 patients with bone metastasis were at the end of life (EOL). Integration of palliative identified, 427 (19.5%) of which were treated with care into the care of AYAO patients may help alleviate RT: 16.6% (2012), 37.5% (2013), 27.4% (2014), patient and family suffering. 18.5% (2015). Median age at diagnosis was 69.2 Research Objectives. This study aimed to describe (IQR 9.0), and 1928 (87.8%) patients were Caucasian. the characteristics of AYAO patients aged 15 to 25 In the 427 patients treated with RT, 25.8%, 37.0%, and years who died in the hospital and to compare the ex- 33.0% were treated in 2012, 2013, and 2014. The top 4 periences of AYAO patients who did and did not primary sites were: genitourinary (22.7%), breast receive palliative care. (20.4%), gastrointestinal (15.7%), and lung (10.8%). Methods. An investigator-developed, standardized Overall guideline adherence was 65.1%: 1 fraction in data extraction tool was used to collect information 33.3%, <14 calendar days in 31.9%, and > 14 calendar about demographics, treatment, EOL characteristics, days in 34.9%. Average adherence by upper, middle, and symptoms during the last month of life (LMOL) and lower tertile of sites was 52.0%, 64.5%, 71.5%. for 69 AYAO patients aged 15 to 25 years who died Adherence by primary cancer type was similar: breast while hospitalized. (58.6%), lung (65.2%), gastrointestinal (67.2), and Results. AYAO patients who died in the hospital genitourinary (72.5%). In patients treated < 14 days, were more likely to have a hematologic malig- 4% were treated with either 1 or 2-5 fractions of stereo- nancy and required considerable medical and psy- tactic body radiotherapy. chosocial care and experienced numerous Conclusion. While compliance was high overall with symptoms during the LMOL. When compared to ASTRO CW recommendations, there remained a sig- those patients who received no palliative care nificant portion (36%) of patients who received a pro- involvement, patients followed by the palliative longed course of palliative radiation. care team were less likely to die in the intensive Implications for research, policy or pra- care unit (38% vs. 68%, P ¼ 0.024) and less likely ctice. More research is needed in understanding pa- to have been on a ventilator (34% vs. 63%, tient, provider, and system factors leading to pro- P ¼ 0.028). They also received fewer invasive med- longed fractionation schemes for bone metastasis. ical procedures during the LMOL (median, 1 v. 3 procedures, P ¼ 0.009) and had a do-not-resusci- Palliative Care Involvement Is Associated tate order in place for a longer time before death with Less Intensive End-of-Life Care (median,6vs.2days,P¼ 0.008). Characteristics in Adolescent and Young Conclusion. AYAO patients who died as inpatients Adult Oncology Patients (SA527D) received intensive therapies, had numerous symp- Jennifer Snaman, MD, St. Jude Children’s Research toms, and required significant support from the med- Hospital, Memphis, TN. Jessie Lu, BA Candidate ical and psychosocial teams. Involvement of the (May 2017), University of Pennsylvania, Philadelphia, palliative care team was associated with the receipt of PA. Erica Kaye, MD, St. Jude Children’s Research Hos- less intensive treatments and fewer deaths in the inten- pital, Memphis, TN. Justin Baker, MD FAAHPM, St sive care unit. Jude Children’s Hospital, Memphis, TN. Implications for research, policy or pra- Objectives ctice. Early integration of palliative care into the Describe the end of life characteristics of adoles- routine care of AYAO patients is recommended and cent and young adult oncology patients. should be prospectively studied.