Point-of-Care Ultrasound in the Academic Training of Palliative Medicine Residents

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

The Impact of a Point-of-Care Ultrasound (POCUS) Program to Diagnose and Manage Ascites in Home-based Palliative Care

OBJECTIVE

The objective of this study was to examine the impact of a point-of-care ultrasound (POCUS) program among people with ascites receiving home-based palliative care by measuring the association of POCUS with ascites-related days spent out of the home, compared with outcomes before POCUS implementation.

DESIGN

Open cohort study.

SETTING AND PARTICIPANTS

Adults who had an ascites-related procedure (ARP) between January 1, 2014, and December 31, 2015 (ie, pre-POCUS) and January 1, 2019, and December 31, 2020 (ie, POCUS). An ARP was defined as using ultrasound to diagnose suspected ascites or a paracentesis with or without ultrasound guidance to manage ascites.

METHODS

The main outcome was the rate of ascites-related days spent out of the home, defined as days out of the home for either ARPs or because of ascites-related hospital admissions, relative to the time patients were at risk for spending ascites-related days out of the home.

RESULTS

Among the 103 pre-POCUS patients (mean age 68.0; 50.4% female), there were 161 ARPs with 12.4% occurring at home. Among the 127 POCUS patients (mean age 74.0; 52.0% female) there were 193 ARPs with 82.4% occurring at home. POCUS was associated with a significantly lower rate of ascites-related days spent outside the home (pre-POCUS rate of 33 days per 1000 patient days vs POCUS rate of 9 days; unadjusted incidence rate ratio (IRR), 3.86; 95% CI, 2.95-5.12; P < .001; adjusted IRR, 3.83; 95% CI, 1.27-11.54; P = .02). POCUS was also associated with a higher likelihood of ARPs occurring in the home [unadjusted odds ratio (OR), 32.44; 95% CI, 18.15-59.90; P < .001; adjusted OR, 48.99; 95% CI, 21.04-114.10; P < .001].

CONCLUSIONS AND IMPLICATIONS

The use of POCUS may contribute to maximizing time spent at home for palliative care patients with ascites. These findings support the use of POCUS for home-based palliative care programs.

Point of care ultrasound for rapid assessment and treatment of palliative care patients in acute medical settings

The combination of an ageing population with improving survival in malignant and non-malignant disease processes results in a growing cohort of patients with advanced or end-stage chronic diseases who require acute medical care. Emergency care has historically been stereotyped as the identification and treatment of acute life-threatening problems. Although palliative care may be considered to be new to the formal curriculum of emergency medicine, in many domains the ultrasound skillset of a physician in acute medical care can be efficaciously deployed the benefit of patients with both malignant and non-malignant disease processes that require palliative care in the full breadth of acute healthcare settings. In diagnostic domains (abdominal pain, urinary tract obstruction, dyspnoea, venous thromboembolism and musculoskeletal pain) and for specific intervention guidance (thoracentesis, paracentesis, venous access, regional anaesthesia and musculoskeletal interventions) we suggest that POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications in this important patient population. POCUS is a mandatory competence in the European curriculum of internal medicine, and specific training programs which cover applications in the domains of palliative care in acute care settings are available. Supervision, quality assurance and appropriate documentation are required. We expect that as the availability of mobile units suitable for point of care applications increases, these applications should become standard of care in the acute management of patients who require palliative care.