Literature Review

The patient portal messaging crisisJAMA Neurology; Carrie K. Grouse, MD; Gregory J. Esper, MD, MBA; 12/24The patient portal has improved patient access to medical records and facilitated direct communication between patients and their health care teams, improving patient satisfaction, enhancing health care utilization, and increasing treatment adherence. Work associated with portal messaging has fallen primarily on physicians, requiring time outside clinical work hours to respond. Appointment access limitations have driven more asynchronous care delivery, resulting in more complex and time-consuming messages. This trend is causing higher levels of physician burnout, and female physicians are disproportionately affected. Burnout associated with excessive after-hours work in EHRs [electronic health records] is now noted among neurologists.

Promoting the resilience of health care information systems—The day hospitals stood stillJAMA Health Forum; Daniel B. Kramer, MD, MPH; Kevin Fu, PhD; 11/24On Friday, July 19, 2024, health care workers woke to emails declaring systemwide information technology (IT) emergencies. Because Crowdstrike had access to the most sensitive core parts of the Windows operating system, the automated process caused an immediate global outage of computer systems using the Crowdstrike Falcon product, which is embedded in many computer systems at health care organizations. Rather than accept this event as inherent to a complex, digitized, and wired health care ecosystem, we urge the US Congress, health care regulators, and the public to insist on proactive preventive methods to avoid future IT catastrophic events rather than simply waiting for the next disruptive crisis requiring an emergent response.

International comparison of underlying disease among recipients of medical assistance in dyingJAMA Internal Medicine; Brandon Heidinger, BSc; Colleen Webber, PhD; Kenneth Chambaere, PhD; Eliana Close, PhD; Luc Deliens, PhD; Bregje Onwuteaka-Philipsen, PhD; Thaddeus Pope, JD, PhD; Agnes van der Heide, MD, PhD; Ben White, DPhil, LLB, (Hons); James Downar, MD, MHSc; 12/24In 2023, 282 million individuals lived in jurisdictions allowing medical assistance in dying (MAID). But regardless of jurisdiction, cancer and amyotrophic lateral sclerosis (ALS) consistently account for up to 80% of MAID cases, despite accounting for fewer than 30% of all deaths. This observation is consistent with the idea that MAID is driven heavily by illness-related factors common to people with those illnesses and inconsistent with the idea that MAID is driven substantially by factors that are external to the individual and that vary by jurisdiction, such as eligibility criteria, culture, social assistance, or palliative care service availability. The overall incidence of MAID increased over time (per 1 calendar year ... )

Advance care planning, end-of-life preferences, and burdensome care-A pragmatic cluster randomized clinical trialJAMA Internal Medicine; Jennifer L. Wolff, PhD; Danny Scerpella, MPH; Erin R. Giovannetti, PhD; David L. Roth, PhD; Valecia Hanna, MS; Naaz Hussain, MD; Jessica L. Colburn, MD; Martha Abshire Saylor, PhD; Cynthia M. Boyd, MD; Valerie Cotter, DrNP; Maura McGuire, MD; Christine Rawlinson, MSN, RN; Danetta H. Sloan, PhD; Thomas M. Richards, MS; Kathryn Walker, PharmD; Kelly M. Smith, PhD; Sydney M. Dy, MD; for the SHARING Choices Investigators; 12/24Advance care planning (ACP) is a communication process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. In this pragmatic cluster randomized clinical trial, the SHARING Choices intervention increased new documentation of end-of-life preferences but also increased potentially burdensome care at end of life. Mixed findings underscore the importance of comprehensive support for those with serious illness and prioritizing patient-relevant outcomes in ACP interventional research. 

Allostatic load, educational attainment, and risk of cancer mortality among US menJAMA Network Open; Cynthia Li, BS, MD; Sydney P. Howard, DrPH, MS; Charles R. Rogers, PhD, MPH, MS, MCHES; Sydney Andrzejak, MS; Keon L. Gilbert, DrPH; Keith J. Watts, PhD, MSW; Malcolm S. Bevel, PhD, MSPH; Myles D. Moody, PhD, MA; Marvin E. Langston, PhD; Judah V. Doty, MS; Adetunji T. Toriola, MD, PhD, MPH; Darwin Conwell, MD, MSc; Justin X. Moore, PhD, MPH; 12/24Social determinants of health, such as income, occupation, and education, can influence cancer disparities in men. Men with limited access to education and income are more likely to have high allostatic load (AL), a measure of cumulative physiologic stress on the body over time. Chronic stress triggers prolonged neuroendocrine responses, resulting in elevated proinflammatory cytokines, catecholamines, and other proteins. This overactivation can lead to physiologic dysregulation and can promote cancer development. The findings indicate that men with lower educational attainment and high AL face up to a 4-fold increased risk of cancer mortality and nearly 70% increased risk of cancer mortality when accounting possible confounders. 

Our unrealized imperative: Integrating mental health care into hospice and palliative careJournal of Palliative Medicine; Susan Block; 12/24The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

Applying natural language processing to electronic health record data—From text to triageJAMA Network Open; Grace K. Sun, BS; Andrew P. Ambrosy, MD; 11/24Most information about a patient’s clinical status, disease progression, and response to treatment lies in qualitative clinician documentation in the electronic health record (EHR). The New York Heart Association (NYHA) classification was developed to standardize functional status assessments and treatment decisions ... [but] ... due to inconsistent implementation in routine care, much of the critical information remains in unstructured EHR data that is difficult to capture and analyze. Natural language processing (NLP) is an emerging tool that uses artificial intelligence to process unstructured or semistructured free-text data, such as the embedded assessments of HF symptom status in clinician documentation. NLP, a field of artificial intelligence that focuses on understanding, interpreting, and generating human language, is capable of evaluating these data and providing large-scale insights into patient progress and treatment response, with some limitations. Overall, these findings suggest that deep learning approaches may be used to address meaningful gaps in clinician documentation.

Care of the patient nearing the end of life in the Neurointensive Care UnitNeurocritical Care; by Hanna Ramsburg, Abigail G Fischer, Meredith MacKenzie Greenle, Corey R Fehnel; 12/24Neurologically critically ill patients present with unique disease trajectories, prognostic uncertainties, and challenges to end-of-life (EOL) care. Acute brain injuries place these patients at risk for underrecognized symptoms and unmet EOL management needs, which can negatively affect their quality of care and lead to complicated grief in surviving loved ones. To care for patients nearing the EOL in the neurointensive care unit, health care clinicians must consider neuroanatomic localization, barriers to symptom assessment and management, unique aspects of the dying process, and EOL management needs. We aim to define current best practices, barriers, and future directions for EOL care of the neurologically critically ill patient.

Trends in hepatocellular carcinoma mortality rates in the US and projections through 2040JAMA Network Open; Sikai Qiu, MM; Jiangying Cai, MM; Zhanpeng Yang, MM; Xinyuan He, MD; Zixuan Xing, MD; Jian Zu, PhD; Enrui Xie, MD; Linda Henry, MD; Custis R. Chong, MD; Esther M. John, MD; Ramsey Cheung, MD; Fanpu Ji, MD, PhD; Mindie H. Nguyen, MD, MAS; 11/24Primary liver cancer imposes a substantial global disease burden, ranking as the sixth most commonly diagnosed cancer worldwide and the third-leading cause of global cancer-related mortality in 2020. In this cross-sectional study of 188,280 HCC [hepatocellular carcinoma]-related deaths, ASMRs [age-standardized mortality rates] increased from 2006 to 2022 and were projected to continue rising until 2040, primarily due to increased deaths from alcohol-associated liver disease (ALD) and metabolic dysfunction–associated steatotic liver disease (MASLD); deaths from viral hepatitis were under control and were projected to decrease. Large disparities were observed in HCC-related ASMRs by age, sex, and race and ethnicity. ...these findings may serve as a reference for public health decision-making and timely identification of groups at high risk of HCC-related death.

Patient, caregiver, and clinician perspectives on the time burdens of cancer careJAMA Network Open; Arjun Gupta, MD; Whitney V. Johnson, MD; Nicole L. Henderson, PhD; Obafemi O. Ogunleye, MEd; Preethiya Sekar, MD; Manju George, MVSc, PhD; Allison Breininger, MA; Michael Anne Kyle, PhD, RN; Christopher M. Booth, MD; Timothy P. Hanna, MD, PhD; Gabrielle B. Rocque, MD; Helen M. Parsons, PhD; Rachel I. Vogel, PhD; Anne H. Blaes, MD, MS; 11/24Cancer and its care impose significant time commitments on patients and care partners. These commitments, along with their associated burden, have recently been conceptualized as the “time toxicity” of cancer care. Patients with advanced solid tumors spend approximately 20% to 30% of their days alive with health care contact. In this qualitative analysis of patients, informal care partners, and clinicians, participants highlighted the diverse sources of time burdens, how these time burdens affected care partners alongside patients, and how the time burdens extended to the wider network around them. Time burdens had outcomes ranging from causing psychosocial distress, and “seemingly short” ambulatory appointments turning into all-day affairs. These findings will guide the oncology community to map, measure, and address time burdens for persons affected by cancer.

Palliative nursing in home health care across the lifespanAmerican Journal of Nursing; by Murali, Komal Patel; Ma, Chenjuan; Harrison, Krista L.; Hunt, Lauren J.; Rosa, William E.; Boyden, Jackelyn Y.; 12/24Primary palliative nursing in home health care (HHC) can be delivered to medically complex patients across the lifespan. Primary palliative nursing provides patient- and family-centered care for serious illness by alleviating the stress and symptoms of illness; coordinating care; and supporting the social, cultural, and psychological aspects of care. In this article, two case scenarios of patients in different phases of life serve as examples of primary palliative nursing in HHC. Key elements and challenges of delivering primary palliative nursing care in HHC are also highlighted.

AI can’t worry about patients, and a clinical ethicist says that mattersJAMA; Yulin Hswen, ScD, MPH; Jennifer Abbasi; 11/24This conversation is part of a series of interviews in which JAMA Network editors and expert guests explore issues surrounding the rapidly evolving intersection of artificial intelligence (AI) and medicine. Today, Hull is an associate professor and serves as associate director of the biomedical ethics program at Yale, where her clinical practice focuses on echocardiography and cardiac care of patients with cancer. She spoke about ethical boundaries for using AI in the clinic in a recent conversation with Yulin Hswen, ScD, MPH, an associate editor at JAMA and the newly launched JAMA+ AI and an assistant professor of epidemiology and biostatistics at the University of California, San Francisco. Medicine is, they remind the reader, “as much art as science, as much a moral endeavor as a technical one.”