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Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.

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Patients with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome have high rates of psychiatric illness. The effective management of these psychiatric conditions can improve a patient's quality of life and may improve antiretroviral adherence. Care providers for patients with HIV infection frequently encounter clinical situations in which psychotropic medications are needed or are being used. Those clinical situations require familiarity with the broad category of medications termed "psychotropic." That familiarity should include a basic understanding of indications, adverse effects, and drug interactions. In particular, it is very important to recognize the many potential interactions based on cytochrome P450 metabolism, which is common to many psychotropics, the protease inhibitors, and the nonnucleoside reverse-transcriptase inhibitors. In a brief review of the use of psychotropic medications in patients with HIV infection, we discuss indications, adverse effects, and drug interactions for commonly used antidepressants, mood stabilizers, anxiolytics, antipsychotics, psychostimulants, and drugs of abuse.Patients with AIDS are at higher risk for mental illness than the general population. Prevalences for major depression among patients with HIV infection only and patients with AIDS have been estimated to be between 15% and 40%, far above the prevalence for the general population [1]. Additionally, mental illness places patients at risk for contracting HIV infection. In a study of 671 patients at the Baltimore City Health Department Sexually Transmitted Disease clinic, a diagnosis of depression was associated with behaviors placing one at risk for HIV infection [2]. That 3%-23% of adults with severe mental illness are HIV infected, compared with 0.6% of the population in the United States, is likely related to such highrisk behavior [3]. Mental illness also impacts a patient's ability to adhere to complicated antiretroviral regimens [4]. Treatment of comorbid mental illness in HIV-infected patients, however, can improve adherence to HAART regimens [5].Psychiatric disorders are under-recognized and under-treated in patients with chronic medical illness. In 1996, an epidemiologic study examined a representative sample of 2864 patients receiving medical care for HIV infection [6]. In addition to finding a 12-month prevalence of nearly 50% for psychiatric illness, 27.2% of all HIV-infected patients receiving medical care were taking a psychotropic drug. Antidepressants were the most common (20.9% of all patients), followed by anxiolytics (16.7%), antipsychotics (4.7%), and psychostimulants (3%). Over one-half of the patients reporting a major depressive disorder were not treated with antidepressants [7].We will discuss the indications and uses of psychotropic medications (antidepressants, anxiolytics, mood stabilizers, antipsychotics, psychostimulants, and drugs of abuse) in the HIV clinic. Our goal is to promote the rational treatment of psychiatric disorders in HIV-infected patien...

Clinician burnout reduces the capacity for providers and health systems to deliver timely, high quality, patient-centered care and increases the risk that clinicians will leave practice. This is especially problematic in hospice and palliative care: patients are often frail, elderly, vulnerable and complex; access to care is often outstripped by need; and demand for clinical experts will increase as palliative care further integrates into usual care. Efforts to mitigate and prevent burnout currently focus on individual clinicians. However, analysis of the problem of burnout should be expanded to include both individual- and systems-level factors as well as solutions; comprehensive interventions must address both. As a society, we hold organizations responsible for acting ethically, especially when it relates to deployment and protection of valuable and constrained resources. We should similarly hold organizations responsible for being ethical stewards of the resource of highly trained and talented clinicians through comprehensive programs to address burnout.

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Context. Immune checkpoint inhibitors (ICIs) are increasingly used to treat a variety of cancers, but comparatively little is known about patient-reported outcomes (PROs) and health-related quality of life (HRQoL) among patients receiving these novel therapies.Objectives. We performed a systematic review to examine PROs and HRQoL among cancer patients receiving ICIs as compared to other anticancer therapies.Methods. We systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing ICIs, PROs, and HRQoL on August 10, 2018. Eligible articles were required to involve cancer patients treated with ICIs and to report PROs and/or HRQoL data.Results. We screened 1453 references and included 15 publications representing 15 randomized controlled trials in our analysis. Studies included several cancer types (melanoma, lung cancer, genitourinary cancer, and head/neck cancer), used four different ICIs (nivolumab, pembrolizumab, atezolizumab, and ipilimumab), and compared ICIs to a wide range of therapies (chemotherapy, targeted therapies, other immunotherapy strategies, and placebo). Studies used a total of seven different PROs to measure HRQOL, most commonly the European Organisation for the Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) (n ¼ 12, 80%). PRO data were reported in a variety of formats and at a variety of time points throughout treatment, which made direct comparison challenging. Some trials (n ¼ 11, 73%) reported PROs on specific symptoms. In general, patients receiving ICIs had similar-to-improved HRQoL and experiences when compared to other therapies.Conclusion. Despite the broad clinical trials experience of ICI therapies across cancer types, relatively few randomized studies reported PROs and patient HRQoL data. Available data suggest that ICIs are well tolerated in terms of HRQoL compared to other anticancer therapies although the conclusions are limited by the heterogeneity of trial designs and outcomes. Currently used instruments may fail to capture important symptomatology unique to ICIs, underscoring a need for PROs designed specifically for ICIs.

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