Reconsidering Empathy: An Interpersonal Approach and Participatory Arts in the Medical Humanities.

Funder: Gates Cambridge Trust; doi: http://dx.doi.org/10.13039/501100005370The decline of empathy among health professional students, highlighted in the literature on health education, is a concern for medical educators. The evidence suggests that empathy decline is likely to stem more from structural problems in the healthcare system rather than from individual deficits of empathy. In this paper, we argue that a focus on direct empathy development is not effective and possibly detrimental to justice-oriented aims. Drawing on critical and narrative theory, we propose an interpersonal approach to enhance empathic capacities that is centered on constructive and transformative interactions which integrates the participatory arts and involves both patients and health professional students. We describe and evaluate a program where patients and students create collaborative, original songs. Interviews and a focus group revealed interactional processes summarized in four themes: reciprocal relationships, interactions in the community, joint goal, and varied collaboration. There was a significant enhancement of positive attitudes about care post-program amongst health professional students. The interpersonal approach may be a preliminary framework for the medical humanities to shift away from a focus on direct empathy development and further towards participatory, co-creative, and justice-oriented approaches to enhance health and thereby empathic capabilities

Reconsidering Empathy: An Interpersonal Approach and Participatory Arts in the Medical Humanities.

Funder: Gates Cambridge Trust; doi: http://dx.doi.org/10.13039/501100005370The decline of empathy among health professional students, highlighted in the literature on health education, is a concern for medical educators. The evidence suggests that empathy decline is likely to stem more from structural problems in the healthcare system rather than from individual deficits of empathy. In this paper, we argue that a focus on direct empathy development is not effective and possibly detrimental to justice-oriented aims. Drawing on critical and narrative theory, we propose an interpersonal approach to enhance empathic capacities that is centered on constructive and transformative interactions which integrates the participatory arts and involves both patients and health professional students. We describe and evaluate a program where patients and students create collaborative, original songs. Interviews and a focus group revealed interactional processes summarized in four themes: reciprocal relationships, interactions in the community, joint goal, and varied collaboration. There was a significant enhancement of positive attitudes about care post-program amongst health professional students. The interpersonal approach may be a preliminary framework for the medical humanities to shift away from a focus on direct empathy development and further towards participatory, co-creative, and justice-oriented approaches to enhance health and thereby empathic capabilities

Estimates of the need for palliative care consultation across United States ICUs using trigger-based model

Rationale: Use of triggers for palliative care consultation has been advocated in intensive care units (ICUs) to ensure appropriate specialist involvement for patients at high risk of unmet palliative care needs. The volume of patients meeting these triggers, and thus the potential workload for providers, is unknown. Objectives: To estimate the prevalence of ICU admissions who met criteria for palliative care consultation using different sets of triggers. Methods: Retrospective cohort study of ICU admissions from Project IMPACT for 2001–2008. We assessed the prevalence of ICU admissions meeting one or more primary palliative care triggers, and prevalence meeting any of multiple sets of triggers. Measurements and Main Results: Overall, 53,124 (13.8%) ICU admissions met one or more primary triggers for palliative care consultation. Variation in prevalence was minimal across different types of units (mean 13.3% in medical ICUs to 15.8% in trauma/burn ICUs; P = 0.41) and individual units (mean 13.8%, median 13.0%, interquartile range, 10.2–16.5%). A comprehensive model combining multiple sets of triggers identified a total of 75,923 (19.7%) ICU admissions requiring palliative care consultation; of them, 85.4% were captured by five triggers: (1) ICU admission after hospital stay greater than or equal to 10 days, (2) multisystem organ failure greater than or equal to three systems, (3) stage IV malignancy, (4) status post cardiac arrest, and (5) intracerebral hemorrhage requiring mechanical ventilation. Conclusions: Approximately one in seven ICU admissions met triggers for palliative care consultation using a single set of triggers, with an upper estimate of one in five patients using multiple sets of triggers; these estimates were consistent across different types of ICUs and individual units. These results may inform staffing requirements for providers to ensure delivery of specialized palliative care to ICU patients nationally

Latent Class Analysis of Specialized Palliative Care Needs in Adult Intensive Care Units from a Single Academic Medical Center

Context: In the intensive care unit (ICU), 14% of patients meet criteria for specialized palliative care, but whether subgroups of patients differ in their palliative care needs is unknown. Objectives: To use latent class analysis (LCA) to separate ICU patients into different classes of palliative care needs, and determine if such classes differ in their palliative care resource requirements. Methods: Retrospective cohort study of ICU patients who received specialized palliative care, August 2013 – August 2015. Reason(s) for consultation were extracted from the initial note and entered into a LCA model to generate mutually exclusive patient classes. Differences in “high use” of palliative care (defined as having ≥ 5 palliative care visits) between classes was assessed using logistic regression, adjusting for age, race, Charlson comorbidity index and length of stay. Results: In a sample of 689 patients, a four-class model provided the most meaningful groupings: 1) Pain and Symptom Management (n=218, 31.6%), 2) Goals of Care and Advance Directives (GCAD) (n=131, 19.0%), 3) All Needs (n=112, 16.3%) and 4) Supportive Care (n=228, 33.1%). In comparison to GCAD patients, all other classes were more likely to require “high use” of palliative care, (adjusted odds ratio (aOR) 2.61, [1.41-4.83] for “All Needs”, aOR 2.01 [1.16-3.50] for “Pain and Symptom Management”, aOR 1.94 [1.12-3.34] for “Supportive Care”). Conclusion: Based on the initial reason for consultation, we identified four classes of palliative care needs amongst critically ill patients, and GCAD patients were least likely to be high-utilizers. These findings may help inform allocation of palliative care resources for this population

Variability in frequency of consultation and needs assessed by PC services across multiple specialty ICUs

Purpose: Although studies have examined multiple aspects of implementing palliative care in an intensive care unit (ICU) setting, how different types of specialty ICU physicians use palliative care consultations is unknown. Methods: We performed a single-center retrospective study from August 2013 - August 2015 to assess differences in use of palliative care consultation among specialized ICUs. We assessed the percentage of patients admitted to each ICU who received a palliative care consultation, the primary reason(s) for consultation, and additional needs addressed during consultation. ICU differences were compared using Chi-squared and Fisher’s exact tests. Results: Among 13,344 admissions to all ICUs, 689 patients (5.2%) received a palliative care consultation. These patients had an in-hospital mortality of 53.1%. Consultation rates differed significantly between ICUs, with 9.8% of patients in the medical ICU (MICU) receiving consultation versus 2.0% in the cardiothoracic ICU (CTICU) and 1.9% in the neurological ICU (NICU) (p<0.001). Reasons for consultation also differed, with MICU physicians consulting for a wide range of reasons, and CTICU and NICU physicians consulting primarily for “Goals of care” and “Patient/family support”. During initial consultation, 94.4% of patients had at least one additional palliative care need addressed, and 83.2% had additional needs addressed during follow-up; the percentage of patients with additional needs was not different between ICUs (initial, p=0.10; follow-up, p=0.98). Conclusions: Across specialty ICUs, the frequency and nature of involvement of palliative care consultants differs markedly. Most patients who received consultation had additional needs addressed, suggesting palliative care needs may be under-recognized by primary teams in some ICUs

Virtual Interinstitutional Palliative Care Consultation during the COVID-19 Pandemic in New York City.

Context: Amid the COVID-19 surge in New York City, the need for palliative care was highlighted. Virtual consultation was introduced to expand specialist-level care to meet demand. Objectives: To examine the outcomes of COVID-19 patients who received virtual palliative care consultation from outside institutions. Design: This is a retrospective case series. Setting/Subjects: Subjects were 34 patients who received virtual palliative care consultation between April 13, 2020, and June 14, 2020. Measurements: Follow-up frequency and duration, code status change, withdrawal of life-sustaining treatment (LST), and multidisciplinary involvement. Results: Twenty-eight patients (82.3%) were in the intensive care unit and 29 patients (85.3%) were on at least two LSTs. Fifteen patients (44.1%) died in the hospital, 9 patients (26.4%) were discharged alive, and 10 patients (29.4%) were signed off. The median frequency of visits was 4.5 (IQR 6) over 11 days follow-up (IQR 17). Code status change was more frequent in deceased patients. LSTs were withdrawn in eight patients (23.5%). Conclusions: Virtual palliative care consultation was feasible during the height of the COVID-19 pandemic