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.

Patients who present after suicide attempts (SA) may experience a wide range of clinical trajectories, from full medical recovery to irreversible neurologic injury, multiorgan failure, or death. Although suicide prevention, risk assessment, and psychiatric treatment after a SA are well represented in the literature, comparatively little guidance exists for palliative care (PC) clinicians consulted after an SA. Care after SA lies at the intersection of critical care, psychiatry, and ethics, and raises distinctive challenges in prognostication, decisional capacity, decisions about life-sustaining treatment, and support for families and clinicians. This manuscript uses the case of Mr. A, a patient with a self-inflicted gunshot wound and uncertain neurologic prognosis, to describe a PC-informed framework for PC clinicians caring for patients after SA. In collaboration with psychiatry, ethics consultants, and the primary team, PC clinicians can help integrate medical and psychiatric prognosis, avoid anchoring on the attempt as evidence of stable values, support families struggling with guilt and stigma, manage distressing symptoms, and guide ethically grounded decision-making.

At-home administration of oral anticancer medications (OAM) limits interactions with healthcare providers, therefore limiting opportunities for symptom management, posing threats to medication adherence. Individuals diagnosed with multiple myeloma (MM) experience symptoms from both disease- and treatment-related factors. Proteins Beta-2 Microglobulin (B2M) and Lactate Dehydrogenase (LDH) are routinely used in disease monitoring, yet their associations with symptoms and regulation via DNA methylation (DNAm) in individuals with MM have not been investigated. This study explored relationships among LDH and B2M proteins; DNAm of genes B2M, LDHA, LDHB; and symptoms in patients prescribed OAMs for MM. This was a 6-month, longitudinal, exploratory analysis. Symptoms were assessed using self-reported measures. Protein levels were extracted from medical records. DNAm of B2M, LDHA, and LDHB promoter regions were quantified via pyrosequencing of peripheral blood samples. Linear mixed modeling explored cross-sectional and longitudinal associations. Significant cross-sectional associations were identified between fatigue, LDHA and B2M DNAm, and B2M protein (p < .02); pain and LDHA and B2M DNAm (p < .05); gastrointestinal disturbances and LDHA DNAm and LDH protein (p < .05); shortness of breath and LDHA DNAm (p < .04); and depression and LDH protein (p < .04). Longitudinal interaction effects were significant for B2M DNAm and fatigue (p < .05), LDHA and B2M DNAm and pain (p < .04), and LDH protein and depression (p < .04). Prognostic proteins B2M and LDH and their gene-level DNAm patterns were significantly associated with symptoms in individuals taking OAMs for MM. These preliminary findings support further exploration of multi-omics pathways underlying symptoms to inform symptom identification and management strategies.

Moderate-to-severe cancer pain is frequently managed with prescription opioids. However, there are many barriers to guideline-concordant prescription opioid management, including stigma surrounding prescription opioids. The goal of this concept mapping study was to work directly with patients to identify actionable treatment targets to inform future behavioral intervention development that can ultimately improve cancer pain management. Investigators were particularly interested in exploring patient perspectives on opioid stigma interventions, given the lack of existing strategies in this area. Investigators conducted concept mapping with 20 patients with advanced cancer pain who endorsed at least one aspect of opioid stigma. Participants responded to a broad focal prompt: "What kinds of supports and problems should people know about when using prescription opioids to treat cancer pain?" Findings revealed 5 "clusters": 1) pain and opioid management; 2) prescription opioid stigma; 3) clinician attitudes about prescription opioids; 4) support and resources; and 5) insurance and pharmacy issues. Salient discussion focused on strategies to improve internalized stigma and reducing stigmatizing clinician attitudes. Future research should develop and test easily accessible multicomponent, contact-based, and/or internalized stigma interventions that integrate psychoeducation and shared decision-making. PERSPECTIVE: This article presents important, actionable intervention targets for improving cancer pain management, with a specific emphasis on addressing opioid stigma. Findings can be used to inform future intervention development efforts that improve patient and clinician skills, including multicomponent, contact-based, and/or internalized stigma interventions, improved psychoeducation, and shared decision-making.

CONTEXT: With increased survival in cancer and other serious illness, palliative care clinicians are increasingly facing decisions about the benefits versus burdens of opioid therapy in individuals with longer prognoses. When a patient who is prescribed opioids develops an opioid use disorder, guidelines recommend transitioning to a medication for opioid use disorder (MOUD) such as buprenorphine. However, how best to communicate this transition is unknown.

OBJECTIVE: We developed a framework for these conversations based on our clinical experience, and, using directed content analysis, we sought to qualitatively evaluate the framework in clinician and non-clinician interviews.

METHODS: We first created a 13-minute demonstration video of a physician-patient interview in which the physician used our proposed skills, and an interview guide. Participants (10 clinicians with experience caring for patients with cancer, 11 individuals with lived experience) reviewed the video, and then were asked to comment on the skills used, and bring up additional skills. We used coding and thematic analysis to identify themes.

CONCLUSION: We identified six themes which refined our initial communication framework: raising a concern directly, balancing boundaries with shared decision-making, expressing empathy, embedding these conversations within a long-term clinician-patient relationship, countering stigma, and preserving positive regard. When a patient prescribed opioid therapy for pain has developed an addiction, clinicians should balance setting clear limits on opioid prescribing with expression of concern. Further, clinicians should work to develop awareness around their own attitude towards the patient with chronic pain and substance use disorder, and actively repudiate stigma in these conversations.

BACKGROUND: Oral anticancer medications are standard care for cancer. Medication adherence influences health outcomes, but valid, reliable measures assessing self-reported medication adherence are limited. Psychometric properties of the PROMIS® Medication Adherence Scale (PMAS) were evaluated in patients prescribed oral anticancer medications for multiple myeloma.

METHODOLOGY: This was a secondary analysis from a longitudinal observational study examining medication adherence, symptoms, quality of life, and financial hardship among individuals prescribed oral anticancer medications for multiple myeloma. PMAS measured self-reported medication adherence. Self-report and medical record data assessed participant characteristics and adherence correlates. Objective medication adherence indices were generated from continuous electronic event monitored data. Internal consistency reliability was estimated using Cronbach's alpha. Dimensionality was assessed with confirmatory factor analysis. Construct validity was assessed considering adherence correlates. Spearman rank-order correlations summarized associations between PMAS and electronic event monitored data.

RESULTS: PMAS items had limited variability, with high adherence over time. Reliability of PMAS scores was adequate (T1 α = 0.82, 95% CI: 0.75, 0.87; T2 α = 0.84, 95% CI: 0.78, 0.89). Confirmatory factor analysis fit was better for sub-scales (Medication Beliefs and Knowledge and Medication Taking Behaviors) than Total scale, particularly for the Medication Beliefs and Knowledge subscale. Adherence correlates were observed as expected between PMAS and age, self-reported cognitive function, symptom severity, and depression. Weak/moderate positive associations were found between PMAS and electronic event monitored data.

CONCLUSIONS: Reliability, two-factor dimensionality, and construct validity were supported, with some evidence of concurrent criterion validity with electronic event monitored adherence data. Additional validation testing is needed to support findings. Evidence supports the feasibility of longitudinal oral anticancer medication adherence assessment monitoring using PMAS.

PURPOSE: HER2-low breast cancer is treatment-relevant, but whether it is clinically distinct from HER2-0 disease remains unclear. We evaluate metastasis-free interval (MFI), first metastatic site, and survival after metastasis among HER2 classes in metastatic breast cancer.

METHODS: We retrospectively examined patients with metastatic breast cancer classified as HER2-0, HER2-low, or HER2-positive. Analyses included the chi-square test of independence, Welch one-way ANOVA, Kaplan-Meier estimation, and binary and ordinal logistic and Cox regression models.

RESULTS: Among 1,599 patients, 647 (40.5%) had HER2-0 tumors, 672 (42%) had HER2-low tumors, and 280 (17.5%) had HER2-positive tumors. HER2-positive tumors had the shortest MFI compared with HER2-low and HER2-0 tumors (median 2.7 vs. 3.3 vs. 3.7 years, respectively; p = 0.002) and lower odds of late recurrence (≥ 5 years) compared with HER2-0 tumors (OR 0.39, 95% CI 0.22-0.68). HER2-low and HER2-0 tumors had similar metastatic timing. First metastatic site differed across HER2 groups in unadjusted analyses, although HER2 status was not independently associated with bone-only or CNS-only presentation in adjusted binary models. In adjusted Cox regression, HER2-low disease (HR 0.85, 95% CI 0.74-0.97) and HER2-positive disease (HR 0.73, 95% CI 0.60-0.88) were associated with lower hazard of death compared with HER2-0 disease.

CONCLUSION: HER2-positive disease was associated with earlier metastatic recurrence but more favorable post-metastatic survival. HER2-low disease had modestly improved post-metastatic survival but otherwise resembled HER2-0 disease in metastatic timing and adjusted metastatic presentation. These findings support HER2-low status for outcome stratification but suggest it may not independently define a distinct metastatic pattern.

CLINICAL TRIAL NUMBER: Not applicable.

BACKGROUND: Goals of care (GOC) discussions are critical conversations between patients, families, and clinicians to ensure medical treatment aligns with patients' values/preferences, especially in the context of serious illness. Despite their importance in enhancing patients' quality of life (QOL) and aligning care plans with values/preferences, GOC discussions occur infrequently due to systemic, clinician, and patient-level barriers. We sought to conduct an updated review of the literature highlighting recent interventions aimed at improving GOC discussions, as summarizing these advancements could help inform clinical practice.

METHODS: We conducted a robust, systematic narrative review to analyze clinical trials from 2010 to 2025 focused on improving GOC discussions among seriously ill patients (defined as individuals with life-limiting illness). Eligible studies included randomized and nonrandomized trials that reported patient-level outcomes. We identified relevant articles by searching PubMed, Web of Science, CINAHL, and Embase databases, extracting data regarding study design, setting, sample, intervention details, and outcomes (mapped in a tabular format to facilitate comparison).

RESULTS: We identified 41 eligible studies conducted in diverse settings (n = 21, 51.2% across hospitals) and serious illness types (n = 21, 51.2% across multiple serious illness), predominantly from the United States (n = 31, 75.6%). Most studies were randomized controlled trials (n = 28; 68.3%), focusing on patient, clinician, system, or combined interventions to enhance GOC discussions. Patient-focused interventions increased readiness and documentation but showed mixed results on clinical outcomes, such as QOL. Clinician and system interventions improved documentation and conversation quality but had inconsistent impacts on healthcare utilization. Combined interventions showed improvements in communication but not consistently in QOL or healthcare utilization.

CONCLUSIONS: This review highlights the robustness and diversity of GOC interventions, emphasizing the trade-offs between scalability, depth, and patient-centeredness. While interventions appeared to increase GOC discussions and documentation, their impact on downstream patient and caregiver outcomes remains limited. Future research should refine measures and quality indicators to better capture the impact of GOC discussions on patient and family well-being, while considering proximal process outcomes and downstream health outcomes.