Publications

• Conservative Management is customized CKD care, symptom management, and support to navigate care across the CKD trajectory through end of life.
• Conservative management is defined by shared decision-making and interdisciplinary teamwork in alliance with patients and care partners.
• Implementation of conservative management hinges on each practice's logistical considerations and resource availability.

Conservative management is holistic and whole-person care for people with kidney failure. This care pathway is often a good choice for patients who prioritize independence, quality of life, and avoidance of burdens associated with life prolonging therapies such as dialysis. This Kidney Health Guidance document aims to provide evidence-based clinical guidance for best practices in conservative management care delivery. Conservative management comprises three components including customized CKD care, symptom management, and smooth navigation of care transitions. This Kidney Health Guidance describes the application of these three components across the illness trajectory, including the role of shared decision-making, care partner engagement, and interdisciplinary collaboration. Practical strategies are outlined for health care professionals to integrate conservative management care delivery into practice.

Early life adversity confers lifelong health risk, and mindfulness-based interventions (MBIs) show promise for mitigating risk. This trial evaluated feasibility and acceptability of remote mindfulness and coping interventions among emerging adults who recalled childhood trauma with the goal to inform an efficacy trial examining stress-related health outcomes. Eighty-one healthy adults (ages 18–29) who recalled physical, emotional, or sexual abuse during childhood were enrolled. Participants were randomly assigned to 2-week mindfulness or coping comparison interventions and completed lab-based and ambulatory assessments at preintervention, postintervention, and one-month follow-up. Primary outcomes included measures of feasibility and acceptability. Global psychosocial outcomes were secondary. Enrollment and retention targets were reached; of 891 people recruited, 81 were eligible and enrolled, and 88% completed the trial. The intervention programs met benchmarks for feasibility, acceptability, and safe implementation. Participants completed 95% of intervention lessons and 59% of daily life practice prompts, and 93% reported positive treatment expectancies. Three mindfulness participants (8%) showed substantial increases in mental health symptoms. No serious adverse events were reported, but 53% of participants had challenging emotional experiences during the training. The assessment protocol was feasible, with 87% of ambulatory assessments and 99% of blood samples collected. There were no group differences on feasibility/acceptability outcomes. Participants in both groups showed medium-sized improvements on global mental health and mindfulness measures. Two-week remote mindfulness and control interventions were feasible and acceptable among adults exposed to childhood trauma. Further work is warranted to evaluate whether MBIs can offset health risk.

Despite numerous calls to action, palliative care remains inadequately integrated into pulmonary–critical care medicine (PCCM) practice and is de-emphasized in PCCM education. Barriers to specialty palliative care demonstrate a clear need for efficient and effective primary palliative care delivered by PCCM clinicians with advanced training. This American Thoracic Society Workshop Report builds on our policy statement on the proactive integration of palliative care in serious respiratory illness with 2 goals: (1) Develop a scalable “PalliPulm” framework to improve palliative care education and practice in PCCM and (2) inform palliative care–focused education and training programs in PCCM to guide future initiatives. We convened an interdisciplinary and interprofessional group of experts between May 2024 and February 2025 over 4 phases: (1) hybrid workshop; (2) virtual breakout groups; (3) nominal group technique and rapid qualitative analysis; and (4) workshop report development. We identified core primary palliative care skills that PCCM trainees and clinicians should obtain and prioritized the most essential skills—that is, symptom management, serious illness communication, and caregiver support in ambulatory settings and serious illness communication, symptom management, palliative care fundamentals, and end of life care in inpatient settings. We describe pragmatic ways to integrate palliative care into PCCM education and offer advanced educational resources. We provide recommendations for framing palliative care to patients and caregivers, illustrate ways to deliver culturally appropriate palliative care, and offer a path for the future of PalliPulm. This report guides PCCM leaders, trainees, and clinicians to establish scalable PalliPulm educational and practice initiatives and improve its integration into practice.

BACKGROUND: Addressing goals of care (GOC) serves a crucial role throughout the course of a patient's illness, but for it to be useful and enduring, documentation must provide enough detail to be actionable for the next clinician. Our aim is to describe GOC documentation content and quality across four clinical specialties (palliative care, hospitalists, internal medicine [IM] residents, and critical care) using structured assessment of high versus low quality documentation.

METHODS: Literature review suggests that five domains are most important for GOC notes: participants, prognosis, patient goals and values, treatment options, and advance directives. As part of an internal quality improvement initiative at our quaternary academic referral center in the Northeast United States, a novel note assessment tool was constructed and iteratively adjusted to achieve 80% interrater reliability. We then used this to review inpatient GOC notes from patients admitted under IM services with or without a palliative care consult (n = 100, 25 notes from each clinical specialty).

RESULTS: Only 69 out of 100 notes could be classified as GOC notes based on our tool and definitions. Except for palliative care specialists, high-quality documentation occurred infrequently in all specialties (palliative care 85.7%, critical care specialists 22.2%, hospitalists 20%, and IM residents 20%). Prognosis was both infrequently and poorly documented in all four groups, including palliative care. The remaining 31 notes were unrelated to GOC and commonly documented clinical updates, code status in isolation, or were left blank.

CONCLUSION: Using a novel assessment tool, we found that, with the general exception of palliative care specialists, GOC documentation was inconsistent and of low quality. This highlights the need to improve the consistency and quality of GOC documentation. We also submit that the definitions and examples outlined in our novel note assessment tool can double as a guide to teach providers how to improve the quality of their GOC documentation.

BACKGROUND: Cancer survivors often experience declining engagement in digital health interventions (DHIs). However, predictors of engagement with provider-guided DHIs remain unclear. Nurse WRITE (Nurse Written Representational Intervention To Ease Symptoms), an effective 8-week nurse-directed symptom management DHI, offers an opportunity to identify factors influencing engagement and enhance intervention efficacy evaluation.

OBJECTIVE: This study aims to (1) understand engagement phenomena (dimensions, influencing factors, and challenges), and (2) assess the relationship between engagement and patient symptom control in Nurse WRITE.

METHODS: In this secondary analysis of the Nurse WRITE arm of a 3-arm symptom management trial, we examined data from 68 women with recurrent ovarian cancer to assess socioaffective and cognitive engagement through message board activity, as well as behavioral engagement through website usage data. Regression analyses examined patient characteristics, engagement, and symptom control perceptions. Through content analysis, we explored participant challenges and activities before disengagement.

RESULTS: Education was significantly associated with selected cognitive, socioaffective, and behavioral engagement indicators, including cognitive activity count, total word count, completion of symptom care plans, and plan reviews after false discovery rate correction. The most common engagement challenges included worsening health and treatment, busy family life, and website difficulties. Moderate and low engagers also experienced confusion about the intervention timeline and process. Among low engagers, 63.2% (24/38) discontinued communication at specific intervention phases: introduction (8/24, 33.3%), symptom representational assessment (5/24, 20.8%), and goal setting and planning (5/24, 20.8%). Improved symptom control at the end of the intervention was significantly associated with overall engagement, cognitive and socioaffective activity count, question completion percentage, total word count, and completed symptom care plans after false discovery rate correction.

CONCLUSIONS: Education was associated with selected cognitive, socioaffective, and behavioral engagement indicators in Nurse WRITE. Future provider-guided DHIs should consider strategies to support participants with lower educational attainment, address common engagement barriers, and reengage participants during critical intervention phases. Meaningful engagement across cognitive, socioaffective, and behavioral dimensions may be important for improving outcomes while balancing protocol adherence with flexibility.

BACKGROUND: Up to 30% of women with breast cancer experience cancer-related cognitive impairment (CRCI) even before they receive treatment. The authors conducted a post hoc analysis to examine the relationship between neighborhood socioeconomic disadvantage and CRCI in treatment-naive postmenopausal women with early stage breast cancer.

METHODS: The Exercise Program in Cancer and Cognition was a single-blind, 6-month, randomized controlled trial evaluating moderate-intensity aerobic exercise versus usual activity on neurocognitive function. By using baseline data from treatment-naive participants (n = 100), neighborhood socioeconomic disadvantage was assessed using the Area Deprivation Index (national percentile). Cognitive function was measured using composite domain scores. Associations were examined using correlation and linear regression analyses, adjusting for potential covariates/confounders.

RESULTS: On average, participants were aged 63 years and had 16 years of education. Greater neighborhood disadvantage was associated with poorer cognitive function in domains of verbal memory (p = .032), working memory (p = .043), mental flexibility (p = .049), and processing speed (p = .026). In adjusted analyses, working memory remained associated with the Area Deprivation Index (p = .019) with adjustment for age; however, associations with the Area Deprivation Index were attenuated for verbal memory after adjustment for education (p = .067), for mental flexibility after adjustment for depressive symptoms (p = .175), and for processing speed after adjustment for age and body mass index (p = .065).

CONCLUSIONS: Neighborhood socioeconomic disadvantage may contribute to cognitive vulnerability before cancer treatment. However, these findings suggest that years of education and depressive symptoms should be factored into the consideration of neighborhood-level factors when assessing CRCI risk among women with breast cancer (Clinicaltrials.gov identifier NCT02793921).

BACKGROUND: Preterm birth affects approximately 10% of U.S. births, and children born preterm face twice the lifetime risk of chronic kidney disease (CKD). Despite this, kidney health surveillance after preterm birth is uncommon. Although clinical decision support (CDS) tools are widely used in pediatric practice, none address CKD risk stratification after preterm birth. This study assessed pediatric clinician perspectives on facilitators and barriers to CDS tool use, in general and for pediatric CKD risk stratification.

METHODS: We conducted a qualitative descriptive study using semistructured interviews with neonatologists, general pediatricians, and pediatric nephrologists in the United States (December 2023-April 2024). Interviews were conducted by video or teleconference, digitally recorded, and professionally transcribed. Thematic analysis followed COREQ guidelines, and sampling continued until thematic saturation was confirmed.

RESULTS: Twenty-five pediatric clinicians participated (44% neonatologists, 44% general pediatricians, and 12% nephrologists; median age 39 years, 76% female, 52% White, 88% non-Hispanic, and 80% academic practice). Clinicians reported strong preferences for CDS tools that efficiently support workflows, integrate with the electronic health record (EHR), and provide actionable recommendations with caregiver education. Key concerns included unintended consequences such as false reassurance, over-referral to nephrology, and care burden for families with limited subspecialty access. All participants endorsed the need for a pediatric CKD risk stratification tool.

CONCLUSIONS: Pediatric clinicians prefer EHR-integrated, evidence-based, family-centered CDS tools to guide CKD risk identification after preterm birth. These findings represent an important step toward developing a pediatric kidney disease risk stratification CDS tool.

OBJECTIVE: Recent growth in hospice has raised concerns about variability in access and quality. This study examines U.S. county-level presence of hospice providers.

METHODS: Quality was assessed using 2023 Centers for Medicare & Medicaid Services Consumer Assessment of Healthcare Providers and Systems Hospice Survey Star Ratings. County-level sociodemographic characteristics were obtained from the U.S. Census Bureau's American Community Survey 2023 five-year sample.

RESULTS: Of 7024 hospice providers, 29.2% had publicly available ratings, of which 55.3% were high quality (>3 stars). Of 3222 counties, at least one hospice provider was located in 41.4%, and a high-quality provider was present in 23.6%. Counties with high-quality providers tend to be urban and have higher income, larger populations, higher education, and lower poverty and uninsurance rates.

CONCLUSIONS: Many U.S. counties have no hospice providers. The presence of high-quality care is markedly lower in rural and poor counties. Missing star ratings limit the utility of public quality data for patient and family decision-making.