Overall, there is scarcity of data on the utility of POCUS in palliative medicine. In one of the first few reports in literature concerning POCUS use in palliative care, Gishen et al. described the use of POCUS in an inpatient unit [16]. The authors reported drainage of ascites as the most common use of POCUS, in addition to other indications. To date, there have been only a few small studies which demonstrated use of POCUS in outpatient palliative care settings [13, 17–20). These smaller studies report on successful assessments using POCUS in hospice settings, as well as preventing unnecessary procedures and trips to the hospital [21–23]. One retrospective chart review reported on patients with ascites in non-hospital settings such as hospice, residential care, and patient homes [13]. The most prevalent pathology in the cohort was ovarian cancer, foFillowed by various GI cancers, Lung, cancers, breast cancers, genitourinary cancers, and cancers of unknown origin. In our study, which included 89 patients, we found a similar distribution of patients across all cancer types (Table 1).
Our retrospective study is the first of its kind to measure the utilization of POCUS in a comprehensive specialist palliative care program which provides patient care across multiple care settings, including homes, long term care facilities and outpatient clinics in addition to hospital based support [8] (Fig. 3). Furthermore, the study highlights the opportunities of POCUS use for a variety of diagnoses, with assessment of peritoneal or pleural fluid being the most common indication [13, 24, 25]. Specifically, POCUS has long been established as a tool to help clinicians distinguish between fluid accumulations causing symptomatic sequelae in patients and other pathologic abnormalities. We notably observed that 47% of our patients received bed-side interventions assisted by POCUS. 53% of patients in our cohort did not require fluid removal, likely due to inadequate amount of fluid present, assessed using POCUS. This is in line with what has been observed in other studies as well. Landers et al reported that 19/32 patients (59%) had fluid accumulation that was removed via POCUS [12]. They also reported another patient where loculated fluid was observed during POCUS assessment, but was not removed due to inaccessibility. Dhamija et al mention that POCUS assessments can help clinicians differentiate abdominal distension due to fluids as compared to other causes, thus reducing unnecessary procedures, which could put the patient at risk of complications such as bowel perforation [10].
Pneumonia is another established cause of morbidity and mortality in patients with advanced life-limiting diagnosis, and is associated with increased discomfort [26, 27]. Considering the different pulmonary causes of distress in palliative care patients, it becomes imperative to effectively diagnose these issues in order to facilitate competent care, and specifically to facilitate discussion around goals of care. POCUS utility has been well documented in differentiating lung pathologies in critically ill patients, including pneumonia, pneumothorax, pulmonary embolism, and obstructive respiratory disorders [28]. However, use of POCUS for diagnosis of pulmonary complexities has been fairly limited in palliative care. We were effectively able to diagnose 13 cases of pneumonia and one pneumothorax, further signifying the utility of POCUS across multiple indications. Using POCUS, we were able to diagnose patients with congestive heart failure exacerbation and bowel obstruction as well, which expands the indications for POCUS. Gishen et al also explored additional indications in their patients, which shed further light on POCUS utility [16]. There is insufficient evidence in literature with regards to POCUS assessments in multiple different sites in the same patient. However, we observed this to be the clinical picture in 10% of our patients, where multiple symptoms led to use of POCUS to diagnose or rule out different etiologies in an individual. Our study adds to the literature by reporting on this unique aspect of the utility of POCUS in such scenarios.
Study Limitations
This study was associated with limitations. First, the data collected in our study did not look at adverse events associated with POCUS guided procedures. Second, the study did not collect health utilization data that would help highlight the cost effectiveness of administering POCUS in the community, an area that can be looked at in future studies. Third, the study was focused on a single site and may not be reproducible at other sites. While many patients had other imaging per clinical standard of care, diagnoses made by POCUS were not routinely confirmed with other imaging modalities. These data can therefore not comment on the sensitivity or specificity of POCUS in our cohort. Finally, the study focused on the outcomes of the use of POCUS for trained palliative care physicians but did not highlight the processes used to provide this training to clinicians.