Reinventing Palliative Care Delivery in the Era of COVID-19: How Telemedicine Can Support End of Life Care.

Telemedicine technology has become essential to healthcare delivery in the COVID-19 era, but concerns remain regarding whether the intimacy and communication that is central to high-quality palliative care will be compromised by the use of this technology. We employed a business model approach to identify the need for system innovation in palliative care, and a quality improvement approach to structure the project. Products from this project included a standard operating procedure for safe use of tablet computers for inpatient palliative care consultations and family visitations; tablet procurement with installation of video telehealth software; and training and education for clinical staff and other stakeholders.

Options of Last Resort: Palliative Sedation, Physician Aid in Dying, and Voluntary Cessation of Eating and Drinking.

Some patients with terminal and degenerative illnesses request assistance to hasten death when suffering is refractory to palliative care, or they strongly desire to maximize their autonomy and dignity and minimize suffering. Palliative sedation (PS), voluntarily stopping eating and drinking (VSED), and physician-assisted death (PAD) are possible options of last resort. A decision to choose PS can be made by an informed surrogate decision maker, whereas intact decision-making capacity is required to choose VSED or PAD.

A National VA Palliative Care Quality Improvement Project for Improving Intensive Care Unit Family Meetings (ICU-FMs).

Background: We sought to increase intensive care unit-family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals.

Measures: Primary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey-Performance Measure (BFS-PM) scores of "excellent."

Intervention: Quality improvement (QI) project, clinical champion, and ICU-FM templates were implemented in nine participating VA facilities.

Pharmacologic Management of Agitation in Patients with Dementia.

Purpose Of Review: Agitation is common among older adults with dementia; its origin may be multi-factorial, and it is often difficult to treat. In this paper, we summarize current knowledge and offer considerations on pharmacologic management of behavioral and psychological symptoms of dementia (BPSD).

Recent Findings: We reviewed human studies published from 2013 to 2018 evaluating pharmacologic management of BPSD manifestations including depressive symptoms, mania, psychosis, and other BPSD, as well as severe agitation without determination of underlying cause.

"Meet Me Where I Am": Removing Barriers to End-of-Life Care for Homeless Veterans and Veterans Without Stable Housing.

Objective:: To describe the barriers and facilitators of end-of-life (EOL) care for Veterans without stable housing (VWSH) as perceived by Veterans at 1 VA medical center and EOL care staff.

Design:: Qualitative descriptive study. Secondary applied content analysis of data from interviews and focus groups in our parent study.

Voluntarily Stopping Eating and Drinking: A Practical Approach for Long-Term Care Facilities.

Some residents of long-term care (LTC) facilities with lethal or serious chronic illnesses may express a wish to hasten their death by voluntarily stopping eating and drinking (VSED). LTC facility clinicians, administrators, and staff must balance resident safety, moral objections to hastened death, and other concerns with resident rights to autonomy, self-determination, and bodily integrity. Initially, requests for hastened death, including VSED must be treated as opportunities to uncover underlying concerns.

Improving Family Meetings in Intensive Care Units: A Quality Improvement Curriculum.

Background: Family meetings in the intensive care unit are associated with beneficial outcomes for patients, their families, and health care systems, yet these meetings often do not occur in a timely, effective, reliable way.

Objective: The Department of Veterans Affairs Comprehensive End-of-Life Care Implementation Center sponsored a national initiative to improve family meetings in Veterans Affairs intensive care units across the United States. Process measures of success for the initiative were identified, including development of a curriculum to support facility-based quality improvement projects to implement high-quality family meetings.

Can health care rationing ever be rational?

Americans' appetite for life-prolonging therapies has led to unsustainable growth in health care costs. It is tempting to target older people for health care rationing based on their disproportionate use of health care resources and lifespan already lived, but aged-based rationing is unacceptable to many. Systems reforms can improve the efficiency of health care and may lessen pressure to ration services, but difficult choices still must be made to limit expensive, marginally beneficial interventions.

Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia.

Ethical conflicts are commonly encountered in the course of delivering end-of-life care in the ICU. Some ethical concerns have legal dimensions, including concerns about inappropriate hastening of death. Despite these concerns, many ICUs do not have explicit policies and procedures for withdrawal of life-sustaining treatments.

The illness experience of older adults near the end of life: a systematic review.

A systematic literature review identified qualitative studies of issues important to older people near the end of their lives, to develop a model of the illness experience near the end of life based on the views of older people. Six elements were identified from 40 studies that comprise a core domain of the experience of illness while dying: burden, suffering, hope, dignity, decision making, and control and autonomy. These elements were interwoven with three main themes: contextual factors, perceptions and concerns, and response to illness.

Low testosterone is associated with decreased function and increased mortality risk: a preliminary study of men in a geriatric rehabilitation unit.

Objectives: To evaluate whether low testosterone levels are associated with greater depression or poorer function in a geriatric rehabilitation unit.

Design: Retrospective review.

Setting: Geriatric rehabilitation unit.

Testosterone supplementation therapy for older men: potential benefits and risks.

Serum testosterone levels decline gradually and progressively with aging in men. Many manifestations associated with aging in men, including muscle atrophy and weakness, osteoporosis, reduced sexual functioning, and increased fat mass, are similar to changes associated with testosterone deficiency in young men. These similarities suggest that testosterone supplementation may prevent or reverse the effects of aging.