Fearing Pain at the End of Life: A Review of Advance Directives

BACKGROUND

Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain.

METHODS

An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life.

RESULTS

Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death.

CONCLUSION

The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.

Trends in HIV-Related Services Offered by Substance Abuse Treatment Facilities

Introduction In the United States, persons who inject drugs (PWID) represent an increasingly vulnerable population, with a high risk of HIV transmission related to needle sharing. This paper aims to investigate the availability of HIV-related services within substance abuse treatment facilities while emphasizing the need for implementing comprehensive harm-reduction strategies in such facilities. Methods This study explores the prevalence and trends regarding HIV-related services within substance abuse treatment facilities in the United States including testing, counseling, early intervention, and medication provision. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed in order to assess trends in HIV-related services from 2013 to 2020. Results Facility response rates revealed an increase in the availability of HIV testing and specialized programs for individuals with HIV. However, there was a contrasting trend with the decline in early intervention and counseling services, only with a slight increase in 2020. Additionally, government-owned facilities demonstrated superior performance in delivering HIV services compared to private facilities. Conclusion This study highlights the dire need for implementing routine opt-out HIV testing within substance abuse treatment facilities in order to identify new cases. Additionally emphasized is the importance of early intervention for this at-risk population. To effectively address these challenges, we suggest considering the adoption of the "Seek, Test, Treat, Retain" model as a potential solution. Increasing access to HIV-related services within substance abuse facilities requires enhanced resource allocation as well as integrated programs. Identifying deficiencies in HIV service integration is crucial to enhancing care and reducing HIV transmission among PWID.

The Florida Clinical Skills Collaborative: A New Regional Consortium for the Assessment of Clinical Skills

Discontinuation of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 Performance Evaluation (2-PE) raised questions about the ability of medical schools to ensure the clinical skills competence of graduating students. In February 2021, representatives from all Florida, United States, allopathic and osteopathic schools initiated a collaboration to address this critically important issue in the evolving landscape of medical education. A 5-point Likert scale survey of all members (n=18/20 individuals representing 10/10 institutions) reveals that initial interest in joining the collaboration was high among both individuals (mean 4.78, SD 0.43) and institutions (mean 4.69, SD 0.48). Most individuals (mean 4.78, SD 0.55) and institutions (mean 4.53, SD 0.72) are highly satisfied with their decision to join. Members most commonly cited a "desire to establish a shared assessment in place of Step 2 CS/2-PE" as their most important reason for joining. Experienced benefits of membership were ranked as the following: 1) Networking, 2) Shared resources for curriculum implementation, 3) Scholarship, and 4) Work towards a shared assessment in place of Step 2 CS/2-PE. Challenges of membership were ranked as the following: 1) Logistics such as scheduling and technology, 2) Agreement on common goals, 3) Total time commitment, and 4) Large group size. Members cited the "administration of a joint assessment pilot" as the highest priority for the coming year. Florida has successfully launched a regional consortium for the assessment of clinical skills competency with high levels of member satisfaction which may serve as a model for future regional consortia.

Service-Learning Programs and Projects for Medical Students Engaged With the Community

Introduction

The medical school curriculum has changed from using the term “pedagogy” to framing adult learning theories with the goal of applying knowledge to a clinical situation or real-life experiences. Service-learning programs (SLPs) in medical schools illustrate one of several adult learning principles and practices now used in today’s curriculum that better prepare medical students for working with a variety of patients. 

Objective

The researchers’ aim was to assess medical students’ learning experiences while participating with nonprofit organizations during a curricula-designed SLP.

Method

The authors analyzed 60 reflective essays over a three-year academic period from 192 medical students placed in teams of two to four. A qualitative study with a thematic analysis research design was employed in our study. This iterative approach allowed the researchers to identify themes and interpret meaning. The study was completed in 2020 using data from 2017-2020.

Results

Four major themes and one overarching theme emerged that reflect adult learning theories including: (1) transfer learning of one’s skills and knowledge to community and practice; (2) articulate a variety of ways to communicate with multiple, diverse community audiences; (3) employ a creative process for quality improvement strategies; (4) create positive trusting and rewarding relationships that highlight an enhanced level of conduct and professionalism. An overarching theme found was: collaboration emerges almost without forethought. Medical educators may find that replicating this SLP into the curriculum infrastructure provides agency and student buy-in. We established an SLP as part of the medical school curriculum that brings privilege and reward to students and to the community. Reflection provides for meaningfulness from SLP and helps students identify how experiential learning affects their professional development as members of the community and future health care providers.

Conclusion

Implementing SLPs into any medical school curriculum strengthens the adult learning theoretical delivery approach. Disseminating projects and lessons learned to and from the community also showcases experiential learning opportunities for medical students and other professionals. Many aspects of awareness from the medical students’ engagement during the SLP emerged. They learned about specific aspects of community engagement and found it a privilege to give and take many lessons from the experiences and opportunities.

Sociodemographic Disparities In Access To COVID-19 Vaccines Upon Initial Rollout In Florida

In this study we explored sociodemographic disparities in COVID-19 vaccine access upon initial rollout at Publix grocery store locations throughout Florida in January 2021. Florida officials reported that they chose Publix stores for the vaccine rollout because the chain has so many stores in the state and was considered at the time to be better prepared than other retailers. Data on education levels, ethnicity, race, percentage at or below the poverty level, and percentage single-parent households were collected from the 2019 census for 974 Florida ZIP codes. We used hotspot analysis to measure spatial clustering of Publix vaccination sites per 100,000 people. We identified hot spots (areas with greater vaccine availability) in moderately populated areas where the population was significantly older, richer, and Whiter than in areas of lower vaccine availability (cold spots). Cold spots were identified in areas of low and high population density, areas with a higher proportion of Hispanic residents, and areas with a higher proportion of single-parent households, including Miami-Dade County and inland regions of Florida. Multivariate analysis showed strong associations between the number of vaccination sites in a ZIP code and race and ethnicity and a weaker association with percentage of residents at or below the poverty level. Future vaccine distribution should continue to be monitored through a socioeconomic lens to help prevent unequal access.

Student Perspectives on Implementing Stop the Bleed Training into Medical School Curriculum

BACKGROUND

Following the Hartford Consensus guidelines and recommendations, third-year medical students from a single institution were offered an optional Stop the Bleed (STB) training course in August 2018. The aim of this study was to assess medical students' confidence in performing bleeding control techniques and teaching others after completing the STB course. The secondary goal was to assess student perception on integrating mandatory STB training into the medical school curriculum.

MATERIALS AND METHODS

A 24-question survey using a 4-point Likert scale was administered to all medical students who completed STB training. Students were anonymously asked to self-report their confidence in performing bleeding control techniques, training others after STB training, and their perception on integrating STB training into medical school curriculum.

RESULTS

After completing the STB course, 95% of students were comfortable applying a tourniquet, 92% of students were confident in packing wounds, and 99% of students could apply direct pressure to wounds to stop bleeding. Overall, 94% of students reported that STB training would be helpful for their clinical rotations.

CONCLUSION

These results demonstrate that medical students are positively impacted by Stop the Bleed courses and validate that the implementation of mandatory STB courses into medical school curriculum will improve medical students' knowledge and skills for hemorrhage control.

Use of amphotropic retroviral vectors for gene transfer in human colon carcinoma cells

Previous studies in rodent models have demonstrated the feasibility of gene transfer to the stem cells of the intestinal epithelium using ecotropic retroviral vectors delivered luminally. This report represents a next step toward targeting the human intestine as a site for somatic gene therapy. The first experiment assessed the viability of amphotropic retroviral vectors in the luminal environment. It was found that after 4 hr at 37 degrees C in luminal effluent, the loss of titer was no greater than when incubated in control media. Likewise, neither the vector nor the target cells were adversely affected by N-acetylcysteine, which is likely to be used as a preparatory agent for mucus removal. To determine whether human intestinal cells are transducible by these vectors, three colon carcinoma cell lines were studied: HT-29, T84, and Caco-2. All were transduced; however, the expression of the reporter gene was highest in the HT-29 cells. Subsequent studies using these cells showed that with regular stocks of vector, gene transfer peaked at a stock dilution of 1/10 and declined at full strength. This problem could be partially overcome by centrifugal concentration of the retroviral stocks. With this approach, gene transfer increased with increasing particles up to 10x regular stock titers but was inefficient at 100x. Overall, these findings provide encouraging evidence that amphotropic retroviral vectors may eventually be used for in vivo gene transfer into human intestinal epithelium. However, they also point to the need for improved methods of concentrating retroviral vectors.

Gene transfer into fetal rat intestine

To assess the fetal intestine as a site for gene therapy, we have explored a xenograft model in which fetal rat intestine is grafted subcutaneously into nu/nu mice. Prior to grafting, the tissue was exposed to a replication-deficient retroviral vector bearing the neo gene. Transduction efficiency was assessed by quantitative polymerase chain reaction (PCR) of neo in DNA recovered from the grafts. Three methods of infection were employed: (i) simple flushing of the fetal intestine with the vector; (ii) incubation with the vector for 2 hr; and (iii) a combination of both. The first method gave the highest transduction efficiencies in terms of both the proportion of samples that were neo-positive and the number of neo-positive cells per sample. Using this approach, the time course of persistence of neo-positive cells was analyzed by collecting grafts at 1 versus 3 weeks post-infection. The results showed approximately five-fold more positive cells at the earlier time point than at the later, suggesting loss of transduced cells due to cell turnover. Nevertheless, the persistence of a portion of the positive cells for at least 3 weeks is encouraging for future studies with fetal intestine.

Improving access to intestinal stem cells as a step toward intestinal gene transfer

In previous studies exploring the intestinal epithelium as a potential site for somatic gene therapy, we concluded that the mucus lining the intestine constitutes a significant barrier to any attempts at gene transfer via the lumenal route. The mucus problem is aggravated by the fact that the epithelial stem cells, which are the logical target for gene transfer, are located deep in the intestinal crypts. The goals of the current study were to develop procedures that would improve accessibility to the intestinal stem cells and which would effect in vivo mucus removal without damaging the underlying epithelium. Initial experiments involved evaluation of the use of distension to improve accessibility to the intestinal crypts and the use of the mucolytic agents dithiothreitol (DTT) and N-acetyl-cysteine (NAC) versus a control solution of phosphate-buffered saline (PBS) for mucus removal. Catheters were inserted in each end of 3-cm terminal ileal segments in anesthetized rats. Two milliliters of agent was instilled into the clamped segment for 2 min, removed, and repeated. Lumenal distension resulted in shortened villi with wider intervillus spacing, thereby improving crypt access. Both NAC and DTT washes removed significant mucus between the villi but failed to reach the crypt lumen. To enhance mucus release from the crypt lumen, pilocarpine was selected due to its cholinergic properties and preferential binding to muscarinic receptors on crypt goblet cells. Pilocarpine given intraperitoneally 30 min prior to the mucolytic or PBS wash resulted in significant eradication of mucus down into the crypt lumen. This effect was still evident 3-4 hr later provided the intestine remained undisturbed.