PALLIATIVE CARE EDUCATION Where are we going? David E. Weissman, MD Palliative Care Leadership...

PALLIATIVE CARE EDUCATION

Where are we going?

David E. Weissman, MDPalliative Care Leadership

CenterMedical College of Wisconsin

Froedtert Hospital

Thank you

Palliative Care Education

Physician Nurse Social Worker Pharmacist Patient / Public Multi-Inter Disciplinary

Palliative Care MD Education

What is required? What is taught? Do trainees feel prepared? New initiatives. What needs to be done. The oncology/palliative care

interface

Palliative Care is …

The care of patients with advanced, progressive disease in whom cure is no longer possible … limited prognosis, focus of care is quality of life. Same philosophy as Hospice

Palliative care extends the hospice philosophy earlier into the disease course.

Palliative Care

Therapies to modify diseaseHospice

Presentation Therapies to

relieve suffering and/or improve quality of life

Bereavement Care

6m Death

1. What is required …

LCME: “Clinical instruction... must include…EOL care.” But what are the standards and

expectations? None currently exist.

What do deans say … EOL education “very important”: 84% Insufficient curricular time: 67% Oppose required courses: 59% Oppose clerkships: 70% Support integrated education into existing coursework: 100% Barriers:

Time, Faculty Expertise and Faculty Interest

Sullivan et al. Acad Med 2004; 79:760-767.

Graduate Education

Review of ACGME requirements in 46 residency/fellowship programs (31/15) (2000)1

Pain, Non-Pain Symptoms, Ethics, Comm. Skills, EOL Clinical Experience, Psychosocial Care, Personal Reflection, Death and Dying

Weissman, DE and Block SA.Academic Medicine 2002;77: 299-304

Review by Specialty

Internal Medicine, Geriatrics, Neurology had greatest content Within Internal Medicine, only Hem/Onc

and Geriatrics had any EOL content

General Surgery and Radiation Oncology added Pall Care requirements in 2001.

ACGME Summary Few requirements Emphasis on requirements w/in hem/onc

and geriatrics; none re: other causes of death

Emphasis on technical over cognitive/ communication/personal awareness

Virtually no requirement for clinical training Impact of new general competencies is

unknown.

What is being taught?

It depends!

a) how you ask the question

b) whom you ask

Curriculum PenetrationPalliative Care

Mandatory Rotation 5 (4%)Part of Req. Course 110 (88%)Separate Elective 32

(25%)Part of Elective 42 (34%)Other 14 (11%)

AAMC 2001; www.aamc.org

Medical College of WisconsinMedical Ethics & Palliative

Care: 15 weeks

Case-based 14  hours Lecture 14  hours OSCE 2 hours

AAMC Database

Annual AMA GME Survey

Is there a structured EOL curriculum?

Family Practice92% Internal Medicine 92% Emergency Medicine 78% Pediatrics 74% Surgery 65%

Barzansky B. et al Academic Medicine 1999; 74:S102-S104

Graduate Education

But, what does “structured” curriculum mean?

Pain: assessment / treatment Non-pain symptoms / syndromes Communication skills Ethics / law Hospice / community resources Terminal care / pt-family experience Provider Self-Care

* Multiple consensus reports

EOL Education *

National EOL Residency Education Project *

Objective: improve residency end of life training/evaluation

394 residency programs (1998-2004) 12 month project to integrate an EOL

curriculum

*Funded by Robert Wood Johnson Foundation

% of Programs with Required End-of-Life Education

0

102030

40506070

8090100

Required Instruction

Pain Assess

Pain Manage

Addiction Assess

Non-Pain Assess

Non-Pain Manage

Communication

Ethics

Hospice

0 20 40 60 80 100

Pain Assess

Pain Manage

Non-Pain Assess

Non-Pain Manage

Communication

Ethics

HospiceObserved

Faculty Rating

Self-Assessed

Knowledge Test

% of Programs Assessing Residents EOL Competencies

The presence of a structured EOL curriculum was rare.

Prior to participation, program directors did not think of EOL care as a coherent educational realm containing discrete instructional domains.

Do trainees feel prepared?

Mailed survey-M4’s at 6 US medical schools Minority of students felt prepared

Symptom management: 49% Discussion of EOL: 33% Culture/spiritual: 22%

Students at schools with greater EOL teaching reported greater self-confidence

Fraser et al. J Pall Med 2001;4:337-343

Medical Students

Graduation QuestionnairePalliative Care Education

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004

Inadeq.

Appro.

Residents Preparation Schwartz, et al (2002): FP residents;

37% little or no precepting/support for EOL care.

Stevens, et al (2003): Residents pre ICU rotation: 79% none or too little teaching in EOL skills.

Sullivan (2004): Residents feel poorly prepared for EOL decision making.

National EOL Residency Education Project

Baseline self-assessment (1997-2004)

Residents and Faculty N = 9227 Int Med; Fam Prac; Neurology; Gen

Surgery Self-Confidence—24 EOL tasks Concerns: ethics/law/malpractice Knowledge: 36 item MCQ test

1

2

3

4

PGY 1 PGY 2 PGY 3 Faculty

Mean Self Confidence26 EOL Clinical Tasks

1

2

3

4

PGY 1 PGY 2 PGY 3 Faculty

Mean Level of Concern:Six Common EOL Clinical Scenarios

Regarding Ethics/Law

Palliative Care Knowledge Exam

Mean Score: 5349 Residents and Faculty;

114 Internal Medicine Residencies

0

20

40

60

80

100

PGY1 PGY2 PGY3 FACULTY IM BC

Residents and faculty do not know, what they do not know; Large ‘arrogance-ignorance gap

No change in data between 1998 and 2004

No difference between specialties Levels of transition are the greatest points

of educational tension for new learning M3, Intern, 1st year Fellow, New Faculty

New Initiatives

Comprehensive needs assessment Experiential opportunities

Hospice rotations Hospital-Palliative Care rotations

Integration of ethics with palliative medicine Communication skills training and

assessment programs Palliative CEX-residency Residency EOL Curriculum Faculty development Materials development

Palliative Education Assessment Tool (PEAT)

14 NY medical schools Intensive needs assessment process (PEAT)

6 domains: Pall Care, Pain, NeuroPscyh, Other symptoms, ethics/law, Comm. Skills, Pt/Family non-clinical perspectives

10/14 completed strategic planning process 67/71 specific goals implemented

Wood EB et al. Academic Medicine 2002 77:285-291

University of Maryland

3rd Year students during Internal Medicine Clerkship--ambulatory module

16 hours-required Didactic Testing Hospice visits Self-study material Writing exercise

Palliative CEX Pilot Project, U Pittsburgh Int Medicine Direct observation of clinical

encounters in EOL communication with formal evaluative process.

95% of participants reported that the exercise increased their self-confidence and competence in EOL discussions.

Fast Facts and Concepts

143 one-page, referenced, summary of key teaching information

Designed for teaching faculty/ residents/nurses/others

Suitable for rounds Mailbox stuffers E-mail network Downloadable to PDA

Available at EPERC (www.eperc.mcw.edu)

Origin: Dr. Eric Warm, UC

End of Life/Palliative Education Resource

Center (EPERC)

Advancing End of Life Care Through an Online

Community of Educational Scholars

EPERCwww.eperc.mcw.edu

National EOL Residency Education Project

Curriculum Reform Project Four specialties Buy-in from National Associations Significant penetration (50% of all IM

programs) Directed at level of Program Director

Included Chief Resident; Program Director and at least one other faculty member

Intervention Needs assessment-baseline data (P Mullan) 2 + 1 day education program

Modeling education delivery Pain, Communication Skills

Instructional design methods Faculty development methods Action Planning for curriculum change Follow-up and Mentoring

Ready-to-use educational materials

Why instructional design?

We learned in the first project year that residency program directors had little understanding of basic instructional design: Writing objectives Matching objectives to learning formats Constructing lesson plans Matching evaluation to objectives

Why Faculty Development?

In the first project year we learned that the program directors, and other faculty who participated, had virtually no expertise in any of the EOL educational domains. The attendees asked for resource material for themselves and their faculty.

New educational programming in:

Pain assessment Pain management Non-pain symptoms Communication skills Clinical EOL experiences Faculty Development Integration into standard teaching formats (e.g.

Morning Report, Grand Rounds)

Seven Outcome Benchmarks

Outcomes—1 year 30% drop-out 70% curriculum changes

New Curriculum integration New faculty development program New QI education initiatives Faculty/Resident Career Impact Hundreds of published abstracts (JPM)

Long-term impact unknown

Summary of EOL TeachingWhat do we know?

Much of EOL clinical learning occurs in the setting of educational tension tension !!

I don’t know what to do … (clinical) I have to learn it … (testing) I’ll get into trouble if I… (legal, ethics)

EOL Tension Points Pain management

Clinical inadequacy Fears: overdose, addiction, regulatory

Treatment withdrawal Clinical inadequacy Fears: legal, malpractice, ethical, religious,

physician culture Family care

Emotional reaction of self Conflicts: culture

Training Level M3, Intern, 1st year fellow, New Faculty

Professional Role Peer pressure Financial pressure

Teaching Methods

Didactic--ok for knowledge but, EOL care involves attitudes and skills

Experiential learning--role play, calculations, treatment planning, hospice home visits, palliative care service rotations

Mentoring / Role Models--Necessary to reinforce positive attitudes

Self-Reflection--trainees must have opportunity to explore personal attitudes and self reflect

Self-Study—a valuable, but underutilized technique.

Ideal Curriculum

Longitudinal M1 Faculty

Graduated increasingly complex knowledge/skills

Experiential mentored clinical experiences

Reflective attitudinal discussions should account for significant teaching time

Interdisciplinary team approach central to care

If I was the emperor king… All medical schools must have

departments/programs of Palliative Care. All teaching hospitals must have a Palliative Care

Consultation Service. All medical students and residents must complete

a one month clinical palliative care rotation. All oncology trainees (Med, XRT, Surg) must

complete a minimum of two months in palliative care clinical rotations.

Training in Palliative Care must include interdisciplinary focus/experience in diverse care settings.

All med students and residents and oncology fellows, must complete training in communication skills that includes competency-based evaluation of specific skills:

Pain Assessment Giving Bad News Leading a Family Goal-Setting Conference Discussing use of artificial hydration-nutrition Discussing Hospice Referral

What now?

Poor application of existing knowledge persists

Pain management Communication skills Ethical/legal principles Medical resource utilization

Bad News

Good News Consensus on what to teach Proven educational methods Excellent educational resource

material Growing cadre of academic

clinician/educators with EOL care as their primary focus

But ….

Bad News

Improvements within individual schools/ residencies still largely relies on the presence or absence of an effective EOL Champion. Someone who combines:

Commitment and Vision Leadership skills Education skills Clinical Skills

Will new champions emerge?

Grant money for big projects is diminishing.

New “hot” educational priorities continue to develop.

Top-down support at the level of medical schools remains marginal at best.

Good News

The biggest motivator for improving EOL care is not coming from medical schools—it is coming from their affiliated hospitals. Improved EOL care leads to:

Cost Savings Improved patient satisfaction Increasing thru-put

Froedtert Hospital/MCW

Palliative Care Audit 2003 PC Referral vs. Usual care $12,500 savings/case for 5 most

common DRGs leading to inpatient death.

Total estimated cost savings: $2.5 million/year CFO: these are real dollars that we can

apply to other expenses

The UHC Palliative Care The UHC Palliative Care Benchmarking ProjectBenchmarking Project

Key Performance Measure

Aggregate

Average

Pain assessment within 48 hours of admission 96.2%

Use of a numeric scale to assess pain 78.1%

Pain relief or reduction within 48 hours of admission

76.0%

Bowel regimen ordered with opioid therapy order

58.6%

Dyspnea assessment within 48 hours of admission

91.3%

Dyspnea relief or reduction within 48 hours of admission

77.5%

Document patient status within 48 hours of admission

22.3%

Psychosocial assessment within 4 days of admission

25.2%

Patient/family meeting within 1 week of admission

39.4%

Plan for discharge disposition documented within 4 days of admission

52.8%

Discharge planner / social services arranged services required for discharge

70.7%

Palliative Care “Bundle” Improves Outcomes

8

10

12

14

16

18

Days

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

ALOS 16.2 12.7

Cost/Case $36,973 $25,053

4 ― 7 (n=248)

8 ― 11 (n=147)

Patients receiving > 8 of the key measures had a >3.6 day shorter LOS and > $11,000 lower cost per case than those patients receiving < 8 measures

Impact of Number of Key interventionsImpact of Number of Key interventions

HF 2.2% (3/135) 63.0% (85/135) 34.8% (47/135)CA 0.0% (0/104) 47.1% (49/104) 52.9% (55/104)HIV 2.4% (1/42) 66.7% (28/42) 31.0% (13/42)RESP 2.5% (3/121) 71.1% (86/121) 26.4% (32/121)

DRG Group 0 ― 3 4 ― 7 8 ― 11

Count of Key Interventions

•More than half (52.9%) of the cancer patients received > 8 of the key measures

•Less than 35% of the HF and respiratory patients received > 8 of the key measures

“Bundle” By Diagnosis Group

Palliative Care Consultation and Key Interventions

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10 11

Number of Key Performance Measures

Per

cen

tag

e o

f C

ases

With PC Consultation Without PC Consultation

Patients receiving a PC consultation more often received > 8 of the key measures from the PC bundle than patients without a PC referral

Oncology—Palliative Care Interface

Increasing recognition that Palliative Care = Excellent Oncology Care US News Best Hospitals Criteria

New models of continuous care that incorporate palliative care seamlessly with oncologic care.

Palliative Care

Therapies to modify diseaseHospice

Presentation Therapies to

relieve suffering and/or improve quality of life

Bereavement Care

6m Death

But, there exists a tension about provider expertise and when palliative care approaches should be applied:

Role definition: Oncologist vs. Palliative Care Specialist.

Realities of treatment: differences in training are reflected in different views of treatment effectiveness.

The fact that conflicts occur is natural

(two species occupying a close ecological niche).

The challenge for the future will be to ensure that the focus of care is on the patient-family; if so, then integrating palliative care into routine oncologic care will be inevitable.

Palliative Care Leadership Centers

Assist hospitals/hospices starting PC programs

Provide 2-3 day site visit with established program

Provide 1 year of mentorship Contact Center to Advance

Palliative Care www.capc.org

Palliative Care Leadership Centers

Medical College of WisconsinMilwaukee, WI

Fairview Health ServicesMinneapolis, MN

Massey Cancer Center of the VCU Medical CenterRichmond, VA

Mount Carmel Health System Palliative Care ServiceColumbus, OH

Palliative Care Center of the BluegrassLexington, KY

University of CaliforniaSan Francisco, CA