Exploring Psychosocial Stressors, Exam Performance, and Grit Among Preclinical Medical Students.

If a society's greatness is measured by how it treats its most vulnerable, we live in discouraging times for the more than 13 million adults and 700,000 children with serious illnesses in the United States of America (U.S.). While progress had been made to improve serious illness care over the past few decades, emerging policies and practices threaten the important role that palliative care plays in the improvement of quality patient care and outcomes throughout the disease continuum and especially at the end of life. In this personal view, we describe three threats to specialty palliative care in the U.S., namely healthcare financing changes, increased privatization of services, and low prioritization of palliative care research in myriad contexts, including pharmaceutical and clinical trial research and development. We subsequently provide guidance for multi-sector actors to address these threats and mitigate harms while optimizing palliative care for U.S. populations. Although seminal international reports suggest that high-income nations, such as the U.S., lead the way in palliative care availability and access, diverse and complex challenges persist., , , The Institute of Medicine's (IOM's) 2014 report as well as subsequent research has found that people living with serious illness are experiencing potentially avoidable suffering and receiving treatments that may lack benefit or are misaligned with their goals. For example, symptoms are commonly under-treated; despite encouraging trends of decreased pain prevalence and severity, more than 30% of patients with metastatic cancer still report moderate to severe levels of pain. Shared decision-making and conversations on treatment preferences happen less than half the time; although most U.S. adults prefer to die at home, one-third of deaths still occur in U.S. hospitals and the place of death for children with serious illness follows similar trends. And high caregiver burden is associated with both increased caregiver mortality and the placement of patients with serious illness in long-term care facilities. While an extensive literature supports specialty palliative care integration for several serious illnesses, including cancer, pulmonary, renal, and liver diseases, heart failure, and in neurology, , , , , , ; suboptimal outcomes are concentrated among the most vulnerable Americans across diseases. A cohort study of 8976 nationally representative decedents ≥65 years of age who died during 2000–2021 demonstrated that lower wealth was associated with a significantly higher symptom burden, partially mediated by higher multimorbidity, functional impairment, and dementia rates. Moreover, multiple studies have identified Black and Hispanic adult patients are less likely to receive medically indicated opioid pain medications at the end-of-life when compared to White patients., , Children are also at high risk for poor serious illness outcomes. Studies have reported worse end-of-life pain-control outcomes among Hispanic children and a review of children's hospital association benchmark reports found that 55% report not having access to hospice care, with 79% reporting no access to respite care for caregivers.