Palliative and End-of-Life Care
Patient-tailored goals-of-care discussions: Is this the new standard?
Goals-of-care discussions can be challenging conversations for even the most seasoned physicians. The challenge often is not just the timing but also knowing how to stitch together the content of the discussion. In most cases, physicians have minimal prior knowledge of patient and family preferences, and this adds to the complexity. In addition, the majority of these discussions happen in the inpatient setting (Mack et al. Ann Intern Med. 2012;156[3]:204) where the acuity of the illness adds to the barriers of effective communication (Fulmer et al. J Am Geriatr Soc. 2018;May 23. doi: 10.1111/jgs.15374. [Epub ahead of print]). Can these discussions be tailored to suit individual patient needs and can such attempts better goals-of-care communication? A recent publication by Curtis et al in JAMA Internal Medicine (2018;178[7]:930) attempts to shed light on these unanswered questions and provide physician guidance to better engage in these critical discussions. The cluster-randomized trial included both clinicians and patients. Patients were sent a survey assessing their individual preferences, and physicians were given a summary and communication tips based on these preferences (Jumpstart-Tips). This simple, cost-effective yet scalable intervention was able to improve the frequency, documentation, and patient-assessed quality of goals-of-care discussions in an outpatient setting. In addition, the delivery of goal-concordant care was increased at 3 months in the subgroup of patients with stable goals. A notable limitation of this study was the low participation among physicians. Further studies will be needed to further dissect the characteristics of participating and nonparticipating physicians. Research will also be needed to ascertain how to seamlessly integrate this into health-care delivery. But one irrefutable point is that interventions to improve communication hold the key to better end-of-life care delivery for our patients with serious illnesses. Drs. Paladino and Bernacki have aptly noted in their commentary (JAMA Intern Med. 2018;178[7]:940): “In the age of precision medicine, one can imagine a future of precision communication, where we….provide customized direction for clinicians to begin these discussions based on patient-specific needs.” One question remains. Will this be the new standard? The answer lies with us, the clinicians. My answer to this is a resounding “Yes,” and I hope early adopters will lead the way and prove me right.
Shine Raju, MD, MBBS
Steering Committee Member
Respiratory Care
Prevention of health-care professional errors in use of inhalers
Asthma affects approximately 300 million people worldwide. The 2018 Global Initiative for Asthma (GINA) guidelines recommend assessing the patient’s inhaler technique on a regular basis (www.ginasthma.org. Updated 2018. Accessed August 1, 2018).
The pressurized metered-dose inhaler (pMDI) and dry powder inhaler (DPI) are the most common aerosolized medication delivery devices.
Proper inhaler technique optimizes delivery of medication, and patients rely on a variety of their health-care providers (HCP) to teach them to use the devices. Unfortunately, evidence demonstrates patients are unable to use their inhalers properly (Sanchis et al. Chest. 2016;150[2]:394). Improper and inadequate inhaler technique is commonly associated with poor disease control, exacerbations, hospitalization stays, and need for systemic corticosteroids and antibiotic therapy (Capanoglu et al. J Asthma. 2015;52[8]:838; Levy et al. Prim Care Respir J. 2013;22:406; Westerik et al. J Asthma. 2015;53[3]:1).
Incorrect inhaler use is attributed to the design of the device, poor patient understanding, and HCPs having insufficient knowledge of the inhalers and performed the correct inhaled technique 15.5% of the time (Plaza et al. J Allergy Clin Immunol Prac. 2018;6[3]:987).
Health-care providers who are directly responsible for managing patients with pulmonary disease must have knowledge of correct inhaler techniques to effectively teach patients and properly assess their use of these devices. The quality of the HCP instruction to the patient is key to reducing poor inhaler technique (Klijn et al. NPJ Prim Care Respir Med. 2017;;27[1]:24. doi: 10.1038/s41533-017-0022-1). Targeted inhaler technique educational programs for HCPs have been shown to improve clinical outcomes of patients with asthma (Myers. Respir Care. 2015;60[8]:1190). The Respiratory Care NetWork is developing HCP and patient handouts for each aerosol delivery device which may be available in early 2019.
De De Gardner, DrPH, RRT-NPS, FCCP
Steering Committee Member