Development and Dissemination of a Neurology Palliative Care Curriculum: Education in Palliative and End-of-Life Care Neurology

Pathways to Neuropalliative Care Practice

As neuropalliative care is better recognized and more widely utilized, there is as great a need for clinicians trained in the field as there is for disease-specific symptom management, advance care planning, and end-of-life care. In this manuscript, we describe potential career trajectories in neuropalliative care. For clinicians, this includes educational and training opportunities within primary neuropalliative care (integrating palliative care principles into usual neurology practice), specialty neuropalliative care (completing a hospice and palliative medicine fellowship), and hospice. We also describe considerations for establishing new clinical neuropalliative practices and highlight neuropalliative education and research as key areas for advancing the field.

Communication in Neuropalliative Care

Serious illness communication needs are high among patients with neurological conditions, from the time of diagnosis to the end of life. This article will highlight unique needs among these patients, strategies for optimizing communication, and techniques to learn and teach these skills along the continuum of a career in neurology.

"Life…Gets Turned Upside-Down…" Opportunities to Improve Palliative Care for High-Grade Glioma

CONTEXT

Early palliative care referral is recommended broadly in oncology. Yet, few patients with high-grade gliomas (HGG) - highly aggressive brain tumors - receive specialty palliative care consultation.

OBJECTIVES

To delineate unique needs of HGG patients relative to other oncology patients according to perceptions of a diverse sample of US palliative medicine physicians and neuro-oncologists in each of the eight domains of palliative care; and to describe contrasts between physician specialties on indications for and timing of specialty palliative care referrals in HGG.

METHODS

Between September 2021 and May 2023, we conducted semi-structured, 40-minute interviews with ten palliative medicine physicians and ten neuro-oncologists. Participants were recruited via purposive sampling for diversity in geographic setting, years in practice, and practice structure. Interviews were audio-recorded, professionally transcribed, and coded by two investigators. Data were analyzed thematically using a qualitative, phenomenological approach.

RESULTS

The palliative care needs of HGG relative to other cancers across palliative care domains are distinguished by poor prognosis, physical and cognitive deficits, and neuropsychiatric symptoms. Themes on indications for palliative care referral differed between neuro-oncologists and palliative physicians. Neuro-oncologists favored selective referral for clinical indications such as high non-neurologic symptom burden requiring time-intensive management. Palliative physicians favored early referral of most HGG patients, to allow for maximal benefit across HGG trajectory.

CONCLUSION

Patients with HGG have unique palliative care needs that affect palliative care delivery across care domains. Bidirectional education, enhanced collaboration, and consensus guidelines may help overcome barriers to specialty palliative care referral.

Machine Learning Identifies Variation in Timing of Palliative Care Consultations Among Traumatic Brain Injury Patients

Background and Objective Timely palliative care involvement offers demonstrable benefits for traumatic brain injury (TBI) patients; however, palliative care consultations (PCCs) are used inconsistently during TBI management. This study aimed to employ advanced machine learning techniques to elucidate the primary drivers of PCC timing variability for TBI patients. Methods Data on admission, hospital course, and outcomes were collected for a cohort of 232 TBI patients who received both PCCs and neurosurgical consultations during the same hospitalization. Principal Component Analysis (PCA) and K-means clustering were used to identify patient phenotypes, which were then compared using Kaplan-Meier analysis. An extreme gradient boosting model (XGBoost) was employed to determine drivers of PCC timing, with model interpretation performed using SHapley Additive exPlanations (SHAP). Results Cluster A (n = 86) consisted mainly of older (median [IQR] = 87 [78, 94] years), White females with mild TBIs and demonstrated the shortest time-to-PCC (2.5 [1.0, 7.0] days). Cluster B (n = 108) also sustained mild TBIs but comprised moderately younger (81 [75, 86] years) married White males with later PCC (5.0 [3.0, 10.8] days). Cluster C (n = 38) represented much younger (46.5 [29.5, 59.8] years), more severely injured, non-White patients with the latest PCC initiation (9.0 [4.2, 17.0] days). The clusters did not differ by discharge disposition (p = 0.4) or frequency inpatient mortality (p > 0.9); however, Kaplan-Meier analysis revealed a significant difference in the time from admission to PCC (p < 0.001), despite no differences in time from admission to mortality (p = 0.18). SHAP analysis of the XGBoost model identified age, sex, and race as the most influential drivers of PCC timing. Conclusions This study highlights crucial disparities in PCC timing for TBI patients and underscores the need for targeted strategies to ensure timely and equitable palliative care integration for this vulnerable population.

Podcast-Based Medical Education and Content Alignment with National Education Bodies

Introduction

Despite the rapid expansion of medical education podcasts in the past decade, there are few efforts to characterize the landscape of available content for specific medical specialties. We trialed a method of rigorous characterization for the field of neurology.

Materials and Methods

Using a censoring date of July 25, 2022, we queried the top three podcast platforms for neurology education podcasts: Apple Podcasts, Spotify, and Google Podcasts. We characterized podcasts based on total number of episodes, episode release frequency, target audience, and affiliation type. We characterized individual episodes by length and primary content area as defined by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Psychiatry and Neurology (ABPN). We compared content availability with content recommendations from these education bodies.

Results

We identified 30 podcasts sharing 1772 episodes and totaling 46,287 min. The ACGME subspecialties most frequently covered were vascular neurology (5082 total min, 11%), neuroimmunology (4,406, 10%), and neuromuscular diseases (3,771, 8%). Subjects that were underrepresented included palliative neurology (89 min, 0.2%), neuropathology (95 min, 0.2%), and bioethics (171 min, 0.4%). The coverage of ABPN examination topics varied substantially from the content distribution for the examination.

Discussion

The current landscape of neurology education podcasts features heterogeneous coverage of topics and varies considerably from recommended distribution of content by national education bodies. As podcasts have tremendous potential in supplementing neurology education, characterizing available content may help various stakeholders in the neurology education pipeline optimize the use of this e-learning modality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01971-0.

Does a novel community-based outpatient palliative care intervention for Parkinson's disease and related disorders improve care? Qualitative results from patients and care partners

BACKGROUND

Palliative care has the potential to address significant unmet needs in people with Parkinson's disease and related disorders, but models that rely on in-person specialty palliative care teams have limited scalability.

AIM

To describe patient and care partner experiences with a novel, community-based palliative care intervention for Parkinson's disease.

DESIGN

Qualitative study embedded in a randomized clinical trial to document participant experiences with a novel palliative care intervention (community neurologist training and remote team-based specialist palliative care). Transcripts were coded and thematically analyzed through a combination of team-based inductive and deductive coding.

SETTING/PARTICIPANTS

Twenty-eight patients and 33 care partners purposively sampled from participants in a randomized clinical trial of a palliative care intervention for Parkinson's disease and related disorders conducted at nine sites.

RESULTS

Benefits of the intervention included management of a wider range of non-motor symptoms, facilitation of conversations about the future, greater engagement with the health care team, and increased referrals to resources. Participants identified areas of improvement, including uptake of palliative care training by community neurologists, additional prognostic counseling, and clarity and timeliness of communication with the multidisciplinary team.

CONCLUSIONS

Clinicians caring for people with Parkinson's disease and related disorders should screen for non-motor symptoms, provide regular prognostic counseling, and refer to specialty palliative care services earlier in the course of illness. Future interventions should be designed to promote uptake of palliative care training by community neurologists and further optimize referral to and coordination with in-person or remote specialty palliative teams.

Patient and Family Outcomes of Community Neurologist Palliative Education and Telehealth Support in Parkinson Disease

Importance

Parkinson disease and related disorders (PDRD) are the fastest growing neurodegenerative illness in terms of prevalence and mortality. As evidence builds to support palliative care (PC) for PDRD, studies are needed to guide implementation.

Objective

To determine whether PC training for neurologists and remote access to a PC team improves outcomes in patients with PDRD in community settings.

Design, Setting, and Participants

This pragmatic, stepped-wedge comparative effectiveness trial enrolled and observed participants from 19 community neurology practices supported by PC teams at 2 academic centers from March 8, 2017, to December 31, 2020. Participants were eligible if they had PDRD and moderate to high PC needs. A total of 612 persons with PDRD were referred; 253 were excluded. Patients were excluded if they had another diagnosis meriting PC, were receiving PC, or were unable or unwilling to follow study procedures. Patients received usual care or the intervention based on when their community neurologist was randomized to start the intervention. Data were analyzed from January 2021 to September 2023.

Intervention

The intervention included (1) PC education for community neurologists and (2) team-based PC support via telehealth.

Main Outcomes and Measures

The primary outcomes were differences at 6 months in patient quality of life (QOL; measured by the Quality of Life in Alzheimer Disease Scale [QOL-AD]) and caregiver burden (Zarit Burden Interview) between the intervention and usual care.

Results

A total of 359 patients with PDRD (233 men [64.9%]; mean [SD] age, 74.0 [8.8] years) and 300 caregivers were enrolled. At 6 months, compared with usual care, participants receiving the intervention had better QOL (QOL-AD score, 0.09 [95% CI, -0.63 to 0.82] vs -0.88 [95% CI, -1.62 to -0.13]; treatment effect estimate, 0.97; 95% CI, 0.07-1.86; P = .03). No significant difference was observed in caregiver burden (Zarit Burden Interview score, 1.19 [95% CI, 0.16 to 2.23] vs 0.55 [95%, -0.44 to 1.54]; treatment effect estimate, 0.64; 95% CI, -0.62 to 1.90; P = .32). Advance directive completion was higher under the intervention (19 of 38 [50%] vs 6 of 31 [19%] among those without directives at the beginning of the study; P = .008). There were no differences in other outcomes.

Conclusions and Relevance

PC education for community neurologists and provision of team-based PC via telehealth is feasible and may improve QOL and advance care planning. Overall treatment effects were small and suggest opportunities to improve both the intervention and implementation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03076671.

Advancing the Neuropalliative Care Approach-A Call to Action

This Viewpoint advocates for the integration of neuropalliative care as a vital practice for supporting patients with neurological disease and their families.

Towards clinical application of implantable brain-computer interfaces for people with late-stage ALS: medical and ethical considerations

Individuals with amyotrophic lateral sclerosis (ALS) frequently develop speech and communication problems in the course of their disease. Currently available augmentative and alternative communication technologies do not present a solution for many people with advanced ALS, because these devices depend on residual and reliable motor activity. Brain-computer interfaces (BCIs) use neural signals for computer control and may allow people with late-stage ALS to communicate even when conventional technology falls short. Recent years have witnessed fast progression in the development and validation of implanted BCIs, which place neural signal recording electrodes in or on the cortex. Eventual widespread clinical application of implanted BCIs as an assistive communication technology for people with ALS will have significant consequences for their daily life, as well as for the clinical management of the disease, among others because of the potential interaction between the BCI and other procedures people with ALS undergo, such as tracheostomy. This article aims to facilitate responsible real-world implementation of implanted BCIs. We review the state of the art of research on implanted BCIs for communication, as well as the medical and ethical implications of the clinical application of this technology. We conclude that the contribution of all BCI stakeholders, including clinicians of the various ALS-related disciplines, will be needed to develop procedures for, and shape the process of, the responsible clinical application of implanted BCIs.

Education in neuropalliative care

The importance and value of providing palliative care for patients with neurologic disease is increasingly recognized. While palliative and neuropalliative specialists may be well-positioned to provide this care, there is a shortage of specialists to address these needs. As a result, much of the upfront palliative care will naturally be provided by the treating neurologist. It is imperative that all neurologists receive quality training in primary palliative care skills. As the subspecialty of neuropalliative care grows, the need for specialty neuropalliative education has arisen. This chapter reviews existing educational initiatives and common neuropalliative-oriented career tracks and identifies opportunities for growth along the continuum of medical education and beyond.