Journal of Pain and Symptom Management

The Existential Question in Palliative Sedation: Reply to Putman et al.

Kevin M. Dirksen, James A. Hynds, Ayesha R. Bhavsar, Katherine Brown-Saltzman — 2013-03-25

Putman et al. provide an important contribution to the palliative sedation literature in evidencing that physicians see a critical difference between intending unconsciousness and merely tolerating it as a foreseen, although unintended consequence. They further examine whether physicians believe that a patient has the right to decide to hasten one's death, a doctor's role therein, and the topic of sedating to unconsciousness for existential suffering. On the basis of this well-powered study of U.S. physicians, the authors claim that “two of three physicians opposed sedation to unconsciousness for existential suffering.” Although their contributions should serve to inform the dialogue regarding the scope and practice of palliative sedation, the implications to be derived about palliative sedation for existential suffering are limited. We identify two areas left unaddressed, with the goal of recommending further attention be directed toward this “existential question.”

Authors' Reply to Dirksen et al.

Michael S. Putman, Farr A. Curlin — 2013-04-08

As Dirksen et al. correctly observe, no single definition of existential suffering exists in the literature. We assessed physicians' opinions about treating the “psychological and spiritual suffering” of patients by sedating the patients to unconsciousness. We believe that the vignette effectively captured the belief-dependent and agent-oriented elements that distinguish existential suffering, while using language that would realistically emerge from a clinical encounter (patients rarely complain explicitly of “existential suffering”). We concede that inferences regarding existential suffering are limited by the extent to which these items convey existential suffering, and we join Dirksen et al. in calling for further research on this subject to see if subtle changes in language lead to significant differences in physicians' responses.

Targeting Near the End of Life in Patients With Cancer

Thomas I Peng Soh, Alvin Seng Cheong Wong — 2013-03-15

We read with interest the recent study by Hui et al. regarding the use of targeted agents at the end of life in patients with cancer. We had earlier published a subset of our study in patients with lung cancer and, recently, the final report of a similar study in our patients with solid tumor malignancies.

Personalizing Treatment Decisions for Cancer Patients at the End of Life: Reply to Soh and Wong

David Hui, Eduardo Bruera — 2013-03-25

We would like to thank Soh and Wong for their insightful comments. They are correct in pointing out that initiation of a new systemic regimen in the last weeks of life is an indicator of aggressive end-of-life care. At the same time, we believe that the use of any chemotherapy in the last weeks of life, as documented in our present study and previous ones, is justified because this is the criterion adopted by the American Society of Clinical Oncology Quality Oncology Practice Initiative and the National Quality Forum. Patients with cancer on systemic therapy should be monitored regularly with a careful assessment before each treatment cycle (e.g., every three to four weeks). The decision to continue, hold, stop, or switch treatment is based on the risks (treatment toxicities), benefits (tumor response), and patient preference. Thus, administration of any systemic therapy, existing or new, when the disease clearly has progressed and/or the patient clearly has declined, calls into question its appropriateness. Given that clinicians often overestimate survival, we need to develop better prognostic and predictive factors to assist with treatment decision making at the end of life.

Locked-In Syndrome as a Result of Cyclizine Administration

Philip Lee — 2013-04-08

Movement disorders, including akathisia, dystonia, and tardive dyskinesia, resulting from the use of antiemetic medications are not uncommon side effects in the palliative care setting. There have been a number of case reports of severe acute dystonic reactions after single doses of cyclizine and of transient paralysis also after single doses of cyclizine.

Repeated Use of Subcutaneous Levetiracetam in a Palliative Care Patient

José Mario López-Saca, Jesús Vaquero, Ana Larumbe, Juli Urdíroz, Carlos Centeno — 2013-03-27

Seizures are one of the clinical manifestations that affect quality of life in patients with cerebral tumors and metastases, and chronic treatment with antiepileptic drugs is necessary. Ideal antiepileptics must offer adequate renal clearance and must not cause neurotoxic side effects or alter hepatic enzymes. New drugs such as levetiracetam and gabapentin are the first choice medications for elderly and terminally ill patients. Levetiracetam has been shown to be safe via oral, intramuscular, or endovenous administration. However, in certain circumstances, its administration may become compromised. We present the case of a patient for whom levetiracetam was used subcutaneously, with clinical benefit and without significant complications.

A Home-Based Exercise Program to Improve Function, Fatigue, and Sleep Quality in Patients With Stage IV Lung and Colorectal Cancer: A Randomized Controlled Trial

2012-09-26

Abstract: Context: Exercise benefits patients with cancer, but studies of home-based approaches, particularly among those with Stage IV disease, remain small and exploratory.Objectives: To conduct an adequately powered trial of a home-based exercise intervention that can be facilely integrated into established delivery and reimbursement structures.Methods: Sixty-six adults with Stage IV lung or colorectal cancer were randomized, in an eight-week trial, to usual care or incremental walking and home-based strength training. The exercising participants were instructed during a single physiotherapy visit and subsequently exercised four days or more per week; training and step-count goals were advanced during bimonthly telephone calls. The primary outcome measure was mobility assessed with the Ambulatory Post Acute Care Basic Mobility Short Form. Secondary outcomes included ratings of pain and sleep quality as well as the ability to perform daily activities (Ambulatory Post Acute Care Daily Activities Short Form), quality of life (Functional Assessment of Cancer Therapy-General), and fatigue (Functional Assessment of Cancer Therapy-Fatigue).Results: Three participants dropped out and seven died (five in the intervention and two in the control group, P=0.28). At Week 8, the intervention group reported improved mobility (P=0.01), fatigue (P=0.02), and sleep quality (P=0.05) compared with the usual care group, but did not differ on the other measures.Conclusion: A home-based exercise program seems capable of improving the mobility, fatigue, and sleep quality of patients with Stage IV lung and colorectal cancer.

Music Therapy Reduces Pain in Palliative Care Patients: A Randomized Controlled Trial

2012-09-26

Abstract: Context: Treatment of pain in palliative care patients is challenging. Adjunctive methods of pain management are desirable. Music therapy offers a nonpharmacologic and safe alternative.Objectives: To determine the efficacy of a single music therapy session to reduce pain in palliative care patients.Methods: Two hundred inpatients at University Hospitals Case Medical Center were enrolled in the study from 2009 to 2011. Patients were randomly assigned to one of two groups: standard care alone (medical and nursing care that included scheduled analgesics) or standard care with music therapy. A clinical nurse specialist administered pre- and post-tests to assess the level of pain using a numeric rating scale as the primary outcome, and the Face, Legs, Activity, Cry, Consolability Scale and the Functional Pain Scale as secondary outcomes. The intervention incorporated music therapist-guided autogenic relaxation and live music.Results: A significantly greater decrease in numeric rating scale pain scores was seen in the music therapy group (difference in means [95% CI] −1.4 [−2.0, −0.8]; P<0.0001). Mean changes in Face, Legs, Activity, Cry, Consolability scores did not differ between study groups (mean difference −0.3, [95% CI] −0.8, 0.1; P>0.05). Mean change in Functional Pain Scale scores was significantly greater in the music therapy group (difference in means −0.5 ([95% CI] −0.8, 0.3; P<0.0001).Conclusion: A single music therapy intervention incorporating therapist-guided autogenic relaxation and live music was effective in lowering pain in palliative care patients.

Family Factors Affect Clinician Attitudes in Pediatric End-of-Life Decision Making: A Randomized Vignette Study

Michael D. Ruppe, Chris Feudtner, Kari R. Hexem, Wynne E. Morrison — 2012-09-26

Abstract: Context: Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children.Objectives: We hypothesized that family factors might influence clinician decision making in these circumstances.Methods: We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed.Results: Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the “involved family” vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6–0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided “futile” care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7–1).Conclusion: In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves.

Emotional Numbness Modifies the Effect of End-of-Life Discussions on End-of-Life Care

Paul K. Maciejewski, Holly G. Prigerson — 2012-08-27

Abstract: Context: Overall, end-of-life (EOL) discussions are unrelated to psychological distress and associated with lower rates of aggressive care near death. Nevertheless, patients who report that they feel emotionally numb about their illness might encounter difficulties cognitively processing an EOL discussion.Objectives: We hypothesized that emotional numbness would modify the effect of EOL discussions on the receipt of less aggressive EOL care.Methods: Data were derived from structured interviews with 290 participants in the federally-funded Coping with Cancer Study, a multisite, prospective cohort study of patients with advanced cancer followed-up till their death. Patients' reports of EOL discussions with their physician and emotional numbness were assessed at a median of 4.6 months before their death. Information about aggressive EOL care (i.e., ventilation, resuscitation in the last week of life, death in the intensive care unit) was obtained from postmortem caregiver interviews and medical charts. Main and interactive effects of EOL discussions and emotional numbness on aggressive EOL care, adjusting for potential confounds, were evaluated using multiple logistic regression.Results: The likelihood of aggressive EOL care associated with having EOL discussions increased by a factor of nine (adjusted odds ratio=9.02, 95% CI 1.37, 59.6, P=0.022) for every unit increase in a patient's emotional numbness score.Conclusion: Emotional numbness diminishes a patient's capacity to benefit from EOL discussions. The EOL decision making may be more effective if clinical communications with emotionally numb patients are avoided.

Both Maintaining Hope and Preparing for Death: Effects of Physicians' and Nurses' Behaviors From Bereaved Family Members' Perspectives

2012-11-19

Abstract: Context: Both maintaining hope and preparing for the patient's death are important for families of terminally ill cancer patients.Objectives: The primary aim of this study was to clarify the level of the family's achievement of maintaining hope and preparing for death and the professional's behavior related to their evaluations.Methods: A cross-sectional, anonymous, nationwide survey was conducted involving 663 bereaved families of cancer patients who had been admitted to 100 palliative care units throughout Japan.Results: A total of 454 family members returned the questionnaire (effective response rate, 68%). Overall, 73% of families reported that they could both maintain hope and prepare for the patient's death. The independent determinants of the family's agreement in reference to the professional's behavior are pacing the explanation with the family's preparation; coordinating patient and family discussions about priorities while the patient was in better condition; willingness to discuss alternative medicine; maximizing efforts to maintain the patient's physical strength (e.g., meals, rehabilitation); discussing specific, achievable goals; and not saying “I can no longer do anything for the patient.”Conclusion: About 20% of family members reported that they could neither “maintain hope nor prepare for death.” A recommended care strategy for medical professionals could include 1) discussing achievable goals and preparing for the future and pacing explanation with the family's preparation, 2) willingness to discuss alternative medicine, 3) maximizing efforts to maintain the patient's physical strength, and 4) avoid saying they could do nothing further for the patient.

Overcoming Barriers to Recruitment in Care of the Dying Research in Hospitals

2012-10-01

Abstract: Context: Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging.Objectives: We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives.Methods: A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, “Is this patient so unwell that you feel they could die on this admission?” to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died.Results: In total, 6642 patients were screened. The ward staff answered “yes” to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate.Conclusion: We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

The Identification of Plasma Proteins Associated With Cancer-Related Fatigue Syndrome (CRFS) in Disease-Free Breast Cancer Patients Using Proteomic Analysis

Ollie Minton, Patrick C. Stone — 2012-09-26

Abstract: Context: Cancer-related fatigue syndrome (CRFS) affects a significant minority of women successfully treated for breast cancer, with symptoms lasting up to several years after finishing therapy.Objectives: This analysis was conducted to identify plasma proteins associated with CRFS in disease-free breast cancer patients.Methods: Women were divided into those meeting the CRFS criteria (cases) and a control group on the basis of a diagnostic interview. Plasma samples were collected from 45 cases and 45 controls. Proteomic analysis was conducted using surface-enhanced laser desorption/ionization, a mass spectrometry (MS) technique. This was followed by further sample processing using one-dimensional gels and trypsin digest for protein identification using liquid chromatography and database searching.Results: CRFS was associated with a statistically significant increase in the intensity of seven MS spectra. A subsequent search of proteins corresponding to the MS spectra identified four acute phase proteins associated with a nonspecific immune response (serum amyloid A, collectin, and subunits of immunoglobulin G and complement C1Q).Conclusion: These novel results (using a technique not previously used in fatigue research) add further weight to the hypothesis that CRFS may be precipitated and prolonged by a nonspecific sustained inflammatory response. Importantly, this has been identified from a global analysis of plasma, which was conducted with no prior assumptions. Although these results need confirmation, we would suggest that future treatments for CRFS should consider focusing on the modulation of this presumed prolonged immune response.

Measuring Relatives' Perspectives on the Quality of Palliative Care: The Consumer Quality Index Palliative Care

2012-09-26

Abstract: Context: A Consumer Quality Index (CQ-index) is a questionnaire assessing the actual care experiences and how important the recipient finds certain care aspects, as well as the priorities for improving quality. A CQ-index Palliative Care (CQ-index PC) for bereaved relatives was developed to measure the quality of palliative care.Objectives: This article provides insight into the development and psychometric characteristics of this questionnaire, as well as quality improvement priorities.Methods: The content of the CQ-index PC was based on existing questionnaires, literature, and interviews and focus group discussions with relatives, patients, and caregivers. The questionnaire was tested in 31 care facilities providing palliative care. Close relatives/contact persons of patients who died non-suddenly six weeks to six months earlier were eligible for inclusion. Psychometric analyses were performed to shorten the questionnaire and to assess its reliability. “Need for improvement scores” also were computed to identify care aspects with the highest priority for quality improvement.Results: Three hundred ninety-two bereaved relatives were eligible for inclusion. The net response was 52% (n=204). Psychometric analyses resulted in six scales (Cronbach's alphas ranging from 0.71 to 0.90). The quality aspects relatives considered most important were dying peacefully, getting help in good time in acute situations, and personal attention. Aftercare was the aspect with the highest priority for quality improvement.Conclusion: The CQ-index PC for relatives can be used to assess the quality of palliative care from the perspective of bereaved relatives. This instrument gives health care professionals insight into care aspects with the highest priority for quality improvement.

Management of Moderate-to-Severe Dyspnea in Hospitalized Patients Receiving Palliative Care

Patama Gomutbutra, David L. O’Riordan, Steven Z. Pantilat — 2012-09-03

Abstract: Context: Benzodiazepines (BZDs) are commonly prescribed for relief of dyspnea in palliative care, yet few data describe their efficacy.Objectives: To describe the management of moderate-to-severe dyspnea in palliative care patients.Methods: Chart review of inpatients with moderate or severe dyspnea on initial evaluation by a palliative care service. We recorded dyspnea scores at follow-up (24 hours later) and use of BZDs and opioids.Results: The records of 115 patients were reviewed. The mean age of patients was 64 years and primary diagnoses included cancer (64%, n=73), heart failure (8%, n=9), and chronic obstructive pulmonary disease (5%, n=6). At initial assessment, 73% (n=84) of the patients had moderate and 27% (n=31) had severe dyspnea. At follow-up, 74% (n=85) of patients reported an improvement in their dyspnea, of which 42% (n=36) had received opioids alone, 37% (n=31) had BZDs concurrent with opioids, 2% (n=2) had BZDs alone, and 19% (n=16) had received neither opioids nor BZDs. Logistic regression analysis identified that patients who received BZDs and opioids had increased odds of improved dyspnea (odds ratio 5.5, 95% CI 1.4, 21.3) compared with those receiving no medications.Conclusion: Most patients reported improvement in dyspnea at 24 hours after palliative care service consultation. Consistent with existing evidence, most patients with dyspnea received opioids but only the combination of opioids and BZDs was independently associated with improvement in dyspnea. Further research on the role of BZDs alone and in combination with opioids may lead to better treatments for this distressing symptom.

The Effect of Severe Androgen Deficiency on Physical Function in Male Patients With Cancer

Bruno Gagnon, Jessica Murphy, Marta Jelowicki, David V. Morris — 2012-10-29

Abstract: Context: Low circulating testosterone concentrations are commonly observed in male patients with cancer and have been shown to be associated with weight loss and increased severity of many symptoms, including fatigue and weakness.Objectives: The aim of the present study was to determine the extent to which testosterone deficiency is associated with poor physical function in male patients with nonhormonal cancers.Methods: We measured serum free testosterone concentration in 101 male patients with cancer evaluated at a nutrition-rehabilitation clinic and performed univariate and multivariate linear regression analyses to assess the effect of a free testosterone concentration in the lowest quartile on six-minute walk distance (6-MWD) (n=100) and maximal gait speed (n=49).Results: In the univariate analyses, patients in the lowest free testosterone quartile had a 6-MWD that was 96m (95% CI 51, 141) less and a maximal gait speed that was 0.26m/second (95% CI 0.06, 0.47) slower on average than patients in the upper three free testosterone quartiles. When controlling for other demographic, clinical, and biological factors, a free testosterone concentration in the lowest quartile was associated, on average, with a 51m (95% CI 44, 97) lower 6-MWD but did not affect maximal gait speed.Conclusion: The present study shows that in male patients with cancer, an extremely low serum free testosterone concentration is independently associated with 6-MWD but not maximal gait speed. Hence, a severe testosterone deficiency may impair their ability to perform sustained activity, but to a lesser degree, short bursts of activity.

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

2012-09-26

Abstract: Context: There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team.Objectives: To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team.Methods: This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams.Results: We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps.Conclusion: We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Facilitating Needs-Based Support and Palliative Care for People With Chronic Heart Failure: Preliminary Evidence for the Acceptability, Inter-Rater Reliability, and Validity of a Needs Assessment Tool

2012-09-26

Abstract: Context: Understanding the types and extent of need is critical to informing needs-based care for people with chronic heart failure (CHF).Objectives: To explore the psychometric quality of a newly developed rapid screening measure to assess the supportive and palliative care needs of people with CHF.Methods: A convenience sample of multidisciplinary health professionals working in heart failure care was invited to comment, via an online survey and consultation, on suitability and required modifications to a validated cancer care needs assessment measure to inform the support and palliative care needs of patients with CHF and their caregivers. Psychometric testing was then undertaken with 52 patients with CHF recruited from a multidisciplinary heart failure service to explore inter-rater reliability and concurrent validity of the newly adapted Needs Assessment Tool: Progressive Disease-Heart Failure (NAT: PD-HF).Results: Health professionals (n=21) rated the tool as easy to administer, comprehensive, and relevant for the CHF population. Prevalence- and bias-adjusted kappa values indicated good agreement between pairs of raters for each item in the NAT: PD-HF (range 0.54–0.90). Participants indicating a higher severity of concern in the NAT: PD-HF physical, daily living, and spiritual items reported significantly higher Heart Failure Needs Assessment Questionnaire physical and existential scores.Conclusion: This study provides preliminary evidence for the NAT: PD-HF as a potential strategy for identifying and informing the management of physical and psychosocial issues experienced by people with CHF. Further work is needed to examine additional psychometrics, benefits relating to unnecessary symptom burden, futile treatments, and admissions to hospital.

Depression in Terminally Ill Patients: Dilemmas in Diagnosis and Treatment

Ali Abbas Asghar-Ali, Kamal C. Wagle, Ursula K. Braun — 2013-04-08

Psychiatric diagnoses are common in up to 50% of patients with incurable conditions. The Canadian National Palliative Care Survey found that 13% of palliative care patients (N = 381) had a diagnosis of major depression. When patients with mild depression, dysthymia, and other depressive disorders were included, the total proportion rose to 44%. Mitchell et al. conducted a recent meta-analysis of 94 psychiatric interview-based studies that assessed cancer patients for depressive disorders. The prevalence of major depressive disorder in both palliative and nonpalliative care settings was found to be 14%, rising to 24% when all forms of depressive illness (minor depression and dysthymia) were included. However, differentiating depressive disorders from an appropriate grief reaction in the setting of a terminal illness may be difficult, and underdetection and undertreatment of the psychological and psychiatric morbidity developed in terminally ill patients are common.

Management of End-of-Life Care and of Difficult Behaviors Associated With Borderline Personality Disorder

Molly A. Feely, Rachel D.A. Havyer, Maria I. Lapid, Keith M. Swetz — 2012-08-27

Psychological suffering is one of the most disconcerting issues that patients and families may experience at the end of life (EOL). In the face of a terminal illness, it is natural for patients to feel grief, sadness, despair, anger, pain, and anxiety. Many are able to achieve acceptance, comfort, and coping through the dying process. However, the dying process can be complicated for those with preexisting psychiatric disorders that make them more vulnerable to distress and may amplify their psychological, emotional, physical, and spiritual suffering.

Buprenorphine

Bethany Foster, Robert Twycross, Mary Mihalyo, Andrew Wilcock — 2013-05-01

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

“Safari ni taabu”: Research and Curriculum Development as an Instrument for Greater Understanding of Spirituality and Love in Health Sciences—Humanistic Personal and Professional Notes on a Journey in Africa

Ikali Karvinen — 2013-05-01

I found here in the West people who were so submerged in the massive trance of modern culture that they appeared virtually unreachable. It became clear that certain topics of discussion, such as spirituality and rituals, were not permitted in intellectual and professional circles. I noticed some people, particularly those who were most enthralled by the game of consumerism, found mention of indigenous wisdom especially irritating and sometimes would lash out at me, just as child entranced by a Nintendo game reacts with a tantrum to any disturbance.—Malidoma Patrice Somé(p. 14)

PC-FACS

Donna S. Zhukovsky — 2013-05-01

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at pc-facs@aahpm.org.