Faculty Bibliography

CONTEXT/BACKGROUND:In spring 2020, New York experienced as surge of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (COVID-19) disease, as part of a global pandemic. There is limited data on populations of COVID-19 infected patients seen by palliative care services. OBJECTIVE:To describe a palliative care population at one New York hospital system during the initial pandemic surge. METHODS:This repeated cross sectional, observational study collected data on palliative care patients in a large health system seen during the COVID-19 outbreak and compared it to pre-COVID data. RESULTS:Palliative service volume surged from 678 (4% of total admissions) pre-COVID-19 to 1,071 (10% of total admissions) during the COVID-19 outbreak. During the outbreak, 695 (64.9%) of palliative patients tested positive for the virus. Compared with a pre-outbreak group, this COVID-19 positive group had higher rates of male (60.7% vs 48.6%, p < 0.01) and Latino (21.3% vs 13.3%; p < 0.01) patients and less white patients (21.3% vs 13.3%; p < 0.01). Our patient's with COVID-19 also had greater prevalence of obesity and diabetes and lower rates of end-stage organ disease and cancers. The COVID-19 positive group had a higher rate of intensive care unit admissions (58.9% vs 33.9%; p < 0.01) and in-hospital mortality rate (57.4% vs 13.1%; p < 0.01) compared to the pre-outbreak group. There was increased odds of mortality in palliative care patients who were COVID-19 positive (OR = 3.21; 95% CI = 2.43 - 4.24) and those admitted to the ICU (OR = 1.45; 95% CI = 1.11 - 1.9). CONCLUSION/CONCLUSIONS:During the initial surge of the COVID-19 pandemic in New York, palliative care services experienced a large surge of patients who tended to be healthier at baseline and more acutely ill at time of admission than pre-COVID palliative patients.

Incapacitated adult patients are commonly divided into two groups for purposes of decision making; those with a surrogate and those without. Respectively, these groups are often referred to as represented and unrepresented, and the relative ethics of decision making between them raises two particular issues. The first issue involves the differential application of the best interests standard between groups. Second is the prevailing notion that representedness and unrepresentedness are categorical phenomena, though it is more aptly understood as a multidimensional and continuous variable based on relational moral authority. This paper examines the nature of representedness as it relates to ethical norms of surrogate decision making.

Objective/UNASSIGNED:Donepezil is widely used to treat Alzheimer's disease (AD), but detecting early response remains challenging for clinicians. Acetylcholine is known to directly modulate attention, particularly under high cognitive conditions, but no studies to date test whether measures of attention under high load can detect early effects of donepezil. We hypothesized that load-dependent attention tasks are sensitive to short-term treatment effects of donepezil, while global and other domain-specific cognitive measures are not. Method/UNASSIGNED:This longitudinal, randomized, double-blind, placebo-controlled pilot trial (ClinicalTrials.gov Identifier: NCT03073876) evaluated 23 participants newly diagnosed with AD initiating de novo donepezil treatment (5 mg). After baseline assessment, participants were randomized into Drug (n = 12) or Placebo (n = 11) groups, and retested after approximately 6 weeks. Cognitive assessment included: (a) attention tasks (Foreperiod Effect, Attentional Blink, and Covert Orienting tasks) measuring processing speed, top-down accuracy, orienting, intra-individual variability, and fatigue; (b) global measures (Alzheimer's Disease Assessment Scale-Cognitive Subscale, Mini-Mental Status Examination, Dementia Rating Scale); and (c) domain-specific measures (memory, language, visuospatial, and executive function). Results/UNASSIGNED:The Drug but not the Placebo group showed benefits of treatment at high-load measures by preserving top-down accuracy, improving intra-individual variability, and averting fatigue. In contrast, other global or cognitive domain-specific measures could not detect treatment effects over the same treatment interval. Conclusions/UNASSIGNED:The pilot-study suggests that attention measures targeting accuracy, variability, and fatigue under high-load conditions could be sensitive to short-term cholinergic treatment. Given the central role of acetylcholine in attentional function, load-dependent attentional measures may be valuable cognitive markers of early treatment response.

Moral distress is a phenomenon increasingly recognized in healthcare that occurs when a clinician is unable to act in a manner consistent with his or her moral requirements due to external constraints. We contend that some experiences of moral distress are self-inflicted due to one's under-assertion of professional authority, and these are potentially avoidable. In this article we outline causes of self-inflicted moral distress and offer recommendations for mitigation.

CONTEXT/BACKGROUND:Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES/OBJECTIVE:To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS:This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS:A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION/CONCLUSIONS:When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.