You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

CME / ABIM MOC / CE

Neurologic Palliative Care Guideline Updates

  • Authors: News Author: Pauline Anderson; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 4/29/2022
  • Valid for credit through: 4/29/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for neurologists, critical care clinicians, internists, pediatricians, nurses, physician assistants, pharmacists, hospice and palliative medicine clinicians, and other members of the health care team involved in neurologic palliative care.

The goal of this activity is for learners to be better able to describe new expert guidance on palliative care for patients with neurologic disorders, based on a position statement developed by a joint committee of the American Academy of Neurology, American Neurological Association, and Child Neurology Society.

Upon completion of this activity, participants will:

  • Assess general recommendations on palliative care for patients with neurologic disorders, based on an updated American Academy of Neurology position statement
  • Evaluate recommendations on palliative care for patients with specific neurologic disorders, based on an updated American Academy of Neurology position statement
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Pauline Anderson

    Freelance writer, Medscape

    Disclosures

    Disclosure: Pauline Anderson has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stocks, stock options, or bonds: AbbVie (former)

Editor

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Lisa Simani, APRN, MS, ACNP, has disclosed no relevant financial relationships.

Compliance Reviewer

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-22-104-H01-P).

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 4/29/2023. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / ABIM MOC / CE

Neurologic Palliative Care Guideline Updates

Authors: News Author: Pauline Anderson; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/29/2022

Valid for credit through: 4/29/2023

processing....

Clinical Context

Palliative care includes much more than hospice services, lead author of the new position statement Lynne P. Taylor, MD, from the University of Washington, Seattle, and a fellow of the AAN, said in a press release. "Neurologists provide palliative care to people living with life-altering neurologic illnesses not just at the end of life but throughout the course of a disease, improving their lives with symptom control," she added.

Palliative care improves quality of life for patients and families with life-changing illness by preventing and managing physical, psychosocial, and spiritual suffering. All clinicians provide primary palliative care; interprofessional teams provide specialty palliative care.

Study Synopsis and Perspective

The American Academy of Neurology (AAN) has released new expert guidance on palliative care for patients with stroke, dementia, Parkinson's disease, and other neurologic disorders. This position statement replaces 3 others regarding supportive care for patients with unique disorders of consciousness: persistent vegetive state, those who are irreve4rsibly paralyzed but retain cognition, and those who lack decisional capacity.

The position paper, developed by a joint committee of the AAN, American Neurological Association, and Child Neurology Society, was published online March 8 in Neurology.

Guidance Across the Life Span

The new paper, an update of previous position statements, includes palliative care guidance for different neurologic disorders across the life span.

For example, neuropalliative care for neonates deserves "extra consideration" because one third of pediatric deaths occur during the neonatal period, most often in the neonatal intensive care unit and after withdrawal of life-sustaining interventions, the investigators note.

For older children, neuropalliative care consultation benefits families trying to maximize the quality of the remainder of their child's life. Decision-making must consider the child's cognitive abilities, the diagnosis, the perceived level of suffering, parental values, and the family's understanding of the prognosis, the authors note.

Also important is engaging in shared decision-making with patients and families.

"This approach requires the physician to elicit a patient's goals, make recommendations based on whether medical treatments are likely to achieve those goals, and work with patients and families to finalize a treatment plan," the new guidance notes.

Ethical Considerations

When treatments are physiologically futile, clinicians need to explain why interventions that may cause harm and have no benefit are not offered.

The authors cite cardiopulmonary resuscitation in the setting of cardiac arrest from irreversible herniation as an example of futility in the context of neurologic disease.

When life-prolonging care is no longer an option, clinicians have an obligation to shift the focus of care to preserving quality of life and comfort as much as possible, they add.

The investigators also broached ethical considerations for individual neurologic conditions. Concerns for disorders of consciousness include misdiagnosis or inaccurate prognostication, and serial examinations are needed to reevaluate levels of cognition, psychological state, decision-making capacity, and disease trajectory.

Stroke, Dementia, Parkinson's Guidance

For stroke, the guidance suggests that neurologists encourage patients with retained decision-making capacity to complete advance care planning, given the risk for recurrent stroke and loss of capacity in the future.

For dementia, a proper and timely diagnosis can help patients and their families prepare for the consequences of cognitive dysfunction and loss of autonomy while respecting their identified values, the authors write.

They note that for Parkinson's disease, which is marked by slow functional and cognitive decline, neurologists must aim to anticipate and treat symptoms, address psychosocial and spiritual distress and caregiver burden, and engage patients and families in advance care planning before onset of cognitive impairment.

It is also important to anticipate patient preferences for future disability-specific decisions, such as those related to feeding tubes and mechanical ventilation, and to identify the patient's minimal acceptable outcome from these life-sustaining interventions.

Well-Timed Update

Commenting for Medscape Medical News, Kate T. Brizzi, MD, a Boston, Massachusetts, neurologist with experience in hospice and palliative care, said that the updated position statement is "well-timed," as neuropalliative care has evolved dramatically during the last decade.

"In the last several years, I've witnessed a significant increase in trainee interest in the field, and there is growing recognition of how a palliative care approach can improve patient care, and hopefully outcomes," said Dr Brizzi.

Dr Brizzi noted that communication tools that help facilitate discussions around shared decision-making "have enhanced our ability to meet the palliative care needs of our patients and can be incorporated by any provider."

There was no targeted funding for this paper. One coauthor reported participation on member adjudication committees for clinical trials for Novo Nordisk, Sunovion, and Galapagos. The remaining authors have disclosed no relevant financial relationships.

Neurology. 2022;98:409-416.[1]

Study Highlights

  • Palliative care encompasses more than just hospice services, which provide comfort-focused medical care and psychosocial and spiritual support to patients with life expectancy of 6 months or less.
  • Neurologists offer palliative care to patients with life-changing neurologic disease throughout the life span and disease course, improving their lives through symptom control.
  • As cognitive decline causes the neurologic patient to transition from primary decision-maker to requiring a surrogate decision-maker, neurologists are ethically bound to apply palliative medicine principles and refer to specialty palliative care when appropriate.
  • Early palliative care consultation may optimize symptom management and facilitate rapport-building and engagement in planning advance care and care goals.
  • Neonates require neuropalliative care, as they account for one third of pediatric deaths, typically in the neonatal intensive care unit after withdrawing life-sustaining interventions.
  • Such care allows families to maximize quality of life and declare advanced directives preferences.
  • Neuropalliative care for older children should maximize quality of life with decision-making, considering the child's cognitive abilities, diagnosis, level of suffering, parental values, and family understanding of prognosis.
  • Primary cause of death for older children is usually progressive respiratory deterioration, creating ethical dilemmas regarding escalating supportive care to sustain life vs invasive ventilation worsening quality of life.
  • The US and most countries prohibit physician-hastened death in assenting adolescents with decision-making capacities, mandating neuropalliative care.
  • Neurologists need training in serious illness communication skills, including delivering bad news, facilitating decision-making, and setting limits regarding objectively futile treatments.
  • Clinicians should discuss prognosis even when uncertain, as patients desire such information, using evidence-based estimates and considering their own personal biases.
  • Treatment plans require shared decision-making with patients and families, based on patient goals and the likelihood that medical treatments could achieve these goals.
  • When treatments are physiologically futile, clinicians should explain why potentially harmful interventions without benefit are not offered.
  • When life-prolonging care is no longer feasible, clinicians should shift focus of care to preserving quality of life and comfort.
  • To avoid misdiagnosis or inaccurate prognosis of disorders of consciousness, serial examinations should reassess cognition, psychological state, decision-making capacity, and disease trajectory.
  • Otherwise, patients with preserved consciousness may be misdiagnosed with disordered consciousness, risking their decisional capacity being ignored.
  • In locked-in syndrome with irreversible paralysis, consciousness may range from minimal consciousness to intact cognition.
  • Such patients may need communication-enhancing techniques from speech pathologists.
  • Neurologists should encourage stroke patients with retained decision-making capacity to complete advance care planning, given future risk for recurrent stroke and loss of capacity.
  • Proper, timely dementia diagnosis can help patients and families prepare for loss of cognitive dysfunction and autonomy while respecting their identified values.
  • Neurologists must anticipate and treat symptoms of Parkinson's disease and related disorders, address psychosocial and spiritual distress and caregiver burden, and engage patients and families in advance care planning before cognitive impairment develops.
  • For patients with ALS, clinicians should document goals and treatment preferences before extreme weakness and aphonia occur, anticipate patient preferences for future disability-specific decisions regarding feeding tubes and mechanical ventilation, and identify the patient's minimal acceptable outcome from life-sustaining interventions.
  • Disease-specific advance directives are available for dementia and ALS.
  • Competent patients have the right to refuse life-prolonging therapies, including artificial nutrition, hydration, mechanical ventilation, and antibiotics.
  • Physicians who morally object to withholding these must transfer care to another physician.
  • Once it is decided to forgo life-sustaining treatment, physicians should minimize subsequent suffering.
  • Most end-of-life symptoms can be managed without sedation.
  • If symptoms require medication doses that may depress consciousness or respiration, the primary intent of the treatment must be relief, not hastening death, even if that is a foreseeable side effect.
  • In a survey of 49 neurology residency programs, 42% of respondents reported dissatisfaction with their palliative care education, particularly regarding nonpain symptom management, pain assessment/management, and addressing spiritual distress.

Clinical Implications

  • Neurologists offer palliative care to patients with life-changing neurologic disease throughout the life span and disease course, improving quality of life through symptom control.
  • Disease-specific advance directives are available for dementia and ALS.
  • Implications for the Health Care Team: Once it is decided to forgo life-sustaining treatment, clinicians should minimize subsequent suffering.

 

Earn Credit

  • Print