Literature Review

Appropriate deprescribing and payment in hospice dementia careJAMA Internal Medicine; Nathan M. Stall, MD, PhD; Sharon K. Inouye, MD, MPH; Lona Mody, MD, MSc; 3/25People living with dementia are one of the largest growing users of hospice care in the US, with approximately 20% of enrollees having a terminal diagnosis of dementia. In the setting of advanced dementia specifically, guidelines recommend deprescribing cholinesterase inhibitors and memantine as there is insufficient evidence for benefit, and there are risks of adverse events including bradycardia, falls, and gastrointestinal adverse effects. The Centers for Medicare & Medicaid Services specifies that hospices are responsible for covering all medications under the Medicare Part A hospice benefit, but audits have revealed that millions of dollars of prescription drug costs are being inappropriately shifted to Medicare Part D. The study by Hunt et al occurs within a context of growing concerns about shifts in US hospice care where more than 70% of hospice agencies serving patients with terminal illness across all settings now operate on a for-profit basis, with increasing acquisition of hospices by private equity firms and publicly traded corporations. Compared with nonprofit hospices, for-profit hospices have more acute care utilization, provide less direct care, and have poorer caregiver-reported care experiences. For-profit hospices also enroll a higher proportion of persons living with dementia, which may relate to their lower acuity and longer stays, as well as more profitable margins under the per-beneficiary daily payment.

Pacemaker and defibrillator deactivation in competent hospice patients: an ethical considerationAmerican Journal of Hospice and Palliative Care; by Jennifer M Ballentine; 1/05In 2003, a Colorado hospice provider asked the DCBC for assistance in developing a policy on deactivation of pacemakers and defibrillators in competent hospice patients. The hospice had encountered concerns from some physicians and cardiac care clinicians that deactivating such devices treads the fine line between legitimate withdrawal of burdensome treatment and assisted death... This article summarizes contributions from the committee's discussion, as well as independent research undertaken by the author.Publisher's note: This older, yet still relevant and helpful, article recently came across my desk.

Prospects for artificial intelligence in health policy and practiceJAMA Health Forum; John Z. Ayanian, MD, MPP; Zirui Song, MD, PhD; 3/25Solving complex diagnostic challenges is a natural application of AI [artificial intelligence] in health care and a compelling way to benchmark its capabilities. The more extraordinary test of AI will be its ability to unravel the ordinary—the everyday needs and struggles faced by patients and clinicians. Which words and what tone should a clinician use to motivate a patient to smoke less, exercise more, or adhere to medications? In these routine, imperfect moments, when the science of medicine morphs into an art of trust, and that art is an inherently human endeavor of caring, how could AI help clinicians choose the words, body language, and tone to deliver better care? The mystery no longer resides in putting together puzzle pieces of data, but rather in piecing together emotions, intuition, and tradeoffs. Improved chronic disease management, more efficient use of societal resources, and better quality of life are among the potential pots of gold at the end of the AI rainbow.  

Ambiguous loss: Implications for perinatal and neonatal nursesNeonatal Network; Rachel A Joseph, Mary Highton; 3/25Ambiguous loss, a term coined by Pauline Boss, is a state in which there is no actual "death" and, therefore, no "grieving" or closure associated with it. Pregnancy is a happy event most of the time; however, the loss of pregnancy can be distressing to the parents. While the birth of a child is expected to be a joyful event, premature birth and subsequent admission to the NICU for prolonged periods with fluctuating conditions force the parent to be in a constant crisis mode where the outcome is unknown. This can mentally, physically, and emotionally drain the parents and may cause depression or other mental health challenges. Perinatal and neonatal nurses are uniquely positioned to recognize the warning signs of emerging grief crises in the parents and support them appropriately.

A mother’s goodbye-Barriers to microtransitions in careJAMA Internal Medicine; Aval-Na’Ree S. Green, MD, MHA, CMD; Benjamin E. Canter, OTD; 3/25After a long, debilitating battle with lupus, my cousin died at the doorsteps of our health system. The funeral was at 11:00 am. I arrived at the facility at 8:45 am. Although the catheter was in place, my aunt was undressed, with remnants of breakfast on her gown. She had not been bathed. The staff and I wheeled my aunt outside and attempted to load her into the van. Once my aunt was in the chair, it could not fit through the van door. Because this transition was not a medical health care appointment, the facility did not coordinate the resources, including use of the van, that were necessary for it to occur successfully. In contrast, had this been a medical outing, such as a weekend dialysis appointment, the facility would have been required to provide transportation. If this microtransition had been treated like a major health care transition, perhaps it would have had a better chance of success. Nursing teams use checklists during major care transitions; similar procedures should apply to microtransitions.

Antimicrobials in serious illness and end-of-life care: Lifting the veil of silenceThe Lancet. Infectious Diseases; William E Rosa, Shila Pandey, Renee Wisniewski, Craig Blinderman, Mark Wing Loong Cheong, Juan Esteban Correa-Morales, Diego Alejandro Cubides-Diaz, Sharif Folorunso, Nahla Gafer, Mohja Marhoom, Tiffanny Newman, Christian Ntizimira, Temitope Oyewole Obadare, Cihan Papan, Pedro Emilio Pérez-Cruz, Lukas Radbruch, Giri Shan Rajahram, Tomás Alejandro Reyes-Barros, Naveen Salins, Kavitha Saravu, Donald R Sullivan, Edward Christopher Dee; 3/25Global rates of antimicrobial consumption increased by 65% between 2000 and 2015, by 16% between 2016 and 2023, and are estimated to increase by an additional 52% by 2030. Antimicrobial use and misuse remains high among people with serious illness and at end of life, despite scarce evidence of benefit. In addition, the overuse and misuse of antimicrobials at end of life further exacerbate antimicrobial resistance, which is a substantial public and global health concern. These examples are combined with a case of non-beneficial end-of-life antimicrobial use and clinical guidance for patient and family communication regarding antimicrobial treatment. This Personal View also provides recommendations to improve antimicrobial stewardship with the goal of engaging multidisciplinary stakeholders and decreasing inappropriate antimicrobial use at end of life.

"Are they just experimenting with all of us?" Cultural considerations for clinicians caring for seriously ill Great Plains American IndiansAmerican Journal of Hospice and Palliative Care; Bethany-Rose Daubman, Tinka Duran, Gina Johnson, Alexander Soltoff, Sara J Purvis, Leroy J R LaPlante, Sean Jackson, Daniel Petereit, Matthew Tobey, Katrina Armstrong, Mary J Isaacson; 3/25Serious illnesses like cancer disproportionately affect American Indians and Alaska Native (AI/AN) Peoples. AI/AN patients deserve culturally responsive healthcare at all times, and especially when journeying through serious illness. Interviews and talking circle qualitative analysis revealed 3 major themes related to clinician needs: cultural considerations, psychosocial support, and trust. It is important for clinicians to engage in cultural education and work to improve systemic deficiencies such as a lack of psychosocial support. An overarching theme was also the need for clinicians to seek to develop trustworthiness and earn trust when caring for AI/AN patients experiencing serious illness.

The intent of the Physician's Order for Life-Sustaining Treatment: Reflecting patient wishes and institutional obligationsJournal of Hospice and Palliative Nursing; Jeannette Jeannie Meyer; 4/25Portable Medical Orders (PMO) such as the Physician's Order for Life-Sustaining Treatment and the Medical Order for Life-Sustaining Treatment have proven to be valuable documents that allow patients who are medically frail or have life-limiting illnesses to communicate their health care wishes. The PMO depends on a conversation between the trained health care provider and the patient or their designee. A PMO with incomplete signatures is not a valid legal document. In the scenario presented here, the author discusses a scenario in which the discussions did not take place and the signatures are questionable, leading the patient to receive aggressive medical treatment that might not be in their best interests. The reasons behind the above ethical issues are related to a misconception and misuse of the PMO within a long-term care facility. Unfortunately, as noted in the literature cited and in the author's own experience, these ethical issues are not uncommon.

A rapid review of psychedelic-assisted therapy in the context of palliative careJournal of Hospice & Palliative Nursing; Miller, Megan PhD, RN; Meyers, Molly BSN, RN; Martin, Annona MSc; Napolitano, Stephanie MA, LMHC; Dorsen, Caroline PhD, FNP-BC; Penn, Andrew MS, PMHNP; Rosa, William E. PhD, MBE, APRN, FPCN; 4/25Psychedelic-assisted therapy (PAT) involves supported experiences with psychedelic medicines in carefully curated environments. Results support safety and initial efficacy of PAT for psycho-spiritual-existential outcomes among carefully screened and highly homogonous samples of patients with serious illness (predominantly cancer). Additional work is needed to (1) explore PAT's safety and efficacy within more diverse samples and contexts, (2) train palliative care providers on PAT, (3) determine systems of care delivery best suited for translation of PAT into practice, and (4) begin developing policy solutions to support safe and equitable access to PAT. Because many patients lack access to basic psychosocial-spiritual-existential care, careful consideration is needed around integration of PAT. The psychedelic substances which are the topic of this article are not currently FDA approved for use in the United States.

Top ten tips palliative care clinicians should know about dysphagia and adult swallowing interventions in serious illnessJournal of Palliative Medicine; Sanora Yonan, Taylor Wilde, Alexa Rogers, Kelly J Trumpatori, Kristie Calix, Christina Barnes, Terri Durkin, Eric Mecusker, Christopher A Jones, Caitlyn M Moore, Laura Chahda, Amanda Stead, Lisa A LaGorio, Paula Leslie; 3/25This article highlights the important role of speech-language pathologists (SLPs) in palliative care (PC), emphasizing their contribution to supporting people with eating, drinking, and swallowing difficulties during serious illnesses and at the end of life. The recommendations underscore the necessity of interdisciplinary collaboration among SLPs and other PC team members, the importance of patient and caregiver education, and the application of patient-centered, comfort-focused approaches to dysphagia intervention. Drawing on current research and expert insights, this article explores the use of SLP services in PC, as well as the challenges in supporting people with eating and drinking difficulties in advanced stages of illness, embedded with practical tips for clinicians.

Trump administration orders NIH to eliminate $2.6 billion in federal contracts STAT; by Megan Moteni; 4/3/25 April 8 is the deadline for a 35% cut in services that could affect specimen storage, genetic counseling, administration. Leaders at the National Institutes of Health have been meeting this week to figure out how to cut $2.6 billion in contracts from the biomedical research agency’s budget, ... Early last week, the Trump administration’s federal government-shrinking task force, known as the U.S. DOGE Service, directed the NIH to reduce contract spending across each of its 27 institutes and centers by roughly 35%. The NIH was told to comply by April 8, ... [Continue reading ... access may be limited by subscription]

Bioethics Artificial Intelligence Advisory (BAIA): An Agentic Artificial Intelligence (AI) framework for bioethical clinical decision support Cureus; by Taposh P. Dutta Roy; 3/12/25 Healthcare professionals face complex ethical dilemmas in clinical settings in cases involving end-of-life care, informed consent, and surrogate decision-making. These nuanced situations often lead to moral distress among care providers. This paper introduces the Bioethics Artificial Intelligence Advisory (BAIA) framework, a novel and innovative approach that leverages artificial intelligence (AI) to support clinical ethical decision-making. The BAIA framework integrates multiple bioethical approaches, including principlism, casuistry, and narrative ethics, with advanced AI capabilities to provide comprehensive decision support. 

Children as living solid organ donors: Ethical discussion and model hospital policy statementThe Journal of Clinical Ethics; Gyan C. Moorthy, Aidan P. Crowley, and Sandra Amaral' Spring 2025In recent years, more attention has been paid to living donation as a means to reduce the suffering of individuals with end-stage kidney or liver disease. Implicated ethical issues include medical risk and risk of coercion, counterbalanced by improved medical outcomes and the benefits of saving a life. Living donation becomes particularly ethically complicated with the prospect of child donation, given the child’s developing autonomy and uniquely dependent status. We outline four broad ethical considerations pertinent to living child organ donation: (1) beneficence, (2) respect for the family as a moral unit, (3) respect for the child as a person, and (4) justice. We conclude that it can be ethical for a healthy child to donate a kidney or liver lobe to a close relative who has exhausted other options provided that certain protections are put into place.