Palliative Care and Geriatrics:Curriculum Development and

ImplementationJames Hallenbeck, MD

Medical Director, VA Hospice Care Center and Stanford Hospice

Questions

• Why teach palliative care in the nursing home?

• Will physicians-in-training be receptive?

• How do I design a curriculum?

• How do you teach in this environment?

Why Teach Palliative Care in the Nursing Home?

• Great overlap between geriatrics and palliative care

• Palliative/EOL care needs are significant

• Gives focus to nursing home/geriatric rotation

• Certain palliative care principles difficult to teach in other environments

Teaching in the Nursing Home-Special Opportunities

• Relatively stable population

• Multiple palliative issues to address

• Patients often have time to talk/teach

• A great place to experience that there is more to healthcare than acute care

Will Physicians-in-training Be Receptive?

• Geriatric training required for internists- nursing home training is not

• Barrier of perception- there’s nothing to learn: ‘just old people waiting to die…”

• Bad news: we have to work harder to overcome this barrier

• Good news: residents are receptive, if they have a good educational experience

Physician Education and Palliative Care

• 90% of medical students have some training– Usually didactic- focus on ethics– Symptom management rarely taught

• Housestaff education largely part of the “resident sub-culture”– Training/modeling by attending physicians

uncommon

Intern Prior Experiences With Death

• 6% reported death of 1st degree relative• 85% reported some training in EOL care

– only one intern reported any training in symptom management

• 55% cared for dying patients only in acute care• 59% had never cared for a dying patient without

an IV

N= 27

Palo Alto VA Intern Hospice Study

Lack of EOL skills

• Pain 2.00 .92• Terminal dyspnea 1.81 .79• Nausea and Vomiting 2.41 1.05• Physical Changes in Dying Process 1.70 .72• Psychological Changes in Dying Process 2.11 .89• Grieving and Dying 2.56 1.12

1= Knew a little, 5= Knew a lotMean SD

Working in a Nursing Home as a physician would be undesirable

3.9 2.8

Working with terminally ill patients in Hospice would be undesirable

3.3 2.3

Exposure to and training in the care of Nursing Home patients is important

3.6 4.6

Exposure to and training in the care of terminally ill (Hospice) patients is important

3.7 4.8

Some training in the care of Nursing Home patients should be mandatory for all internists

3.6 4.6

Some training in the care of terminally ill patients should be mandatory for all internists.

3.8 4.6

ITEM Pre Post

Scale: 1= Strongly Disagree, 5= Strongly agree

P < 0.001 for all

• 22% had never witnessed an attending discuss advanced directives

• 19% had never witnessed an attending share bad news

• 44% had never witnessed an attending tell a family member of a death

A Lack of Attending Modeling

Designing a Curriculum

• Identify your own educational needs- retool as needed

• Address learner’s needs/goals

• Be explicit about your goals for the learner

• Don’t reinvent the wheel– Find and utilize existing educational material

Identifying Your Own Educational Needs

• Strengths: your prior training and experience is a precious resource

• Weaknesses: – Few have been well trained in palliative care– Even those who have been trained have areas of

relative strength and weakness

Educational Resources:• AMA EPEC (Educating Physicians about End of

Life Care) Program• American Academy of Hospice and Palliative

Medicine– Published curriculum– UNIPACS

• Other courses: SFDP, Harvard• Websites: growthhouse.org, eperc.mcw.edu• Textbooks: Oxford Textbook of Palliative Medicine

Adult Learners Are Not Blank Slates

• Most residents have their own goals going into a rotation- identify and address them!

• Common goals:– Pain, non-pain symptom management, learning what

life is like in a nursing home

• Uncommon goals:– Learning how to do the definitive incontinence work-up

– Learning the fine art of disimpaction

What Are Your Goals for Learners?

• Be explicit at beginning of the rotation

• Do not try to convince them that they unconsciously want to be nursing home physicians

• Do include both medical and non-medical goals

Possible Goals• Pain management• Non-pain symptom management• Economics/system issues of nursing home care• What life is like in the nursing home

– For professionals and residents

• Communication skills– Bad news, goal setting, family conferences, conflict resolution

• Self-reflective goals– How do they feel about growing old and going to a nursing

home?

Domains of Palliative Care

Pain Management

Non-pain Symptom Management

Communication

Ethics/Difficult Decisions

Psychosocial, Spiritual Care

System issues

Educational Resources for Learners

• Published curricula, selected articles

• Your own/colleagues handouts

• Videos, websites

• Patients

• Families

• Other staffDon’t try to go it alone!

Teaching in the Nursing Home-Tricks of the Trade

• Link didactic instruction to clinical care– Setting a theme

• Establish different learning experiences– Nurses aide for a day– Aide to different specialty, such as PT – ? Patient for a day– Journal or other writing– Role play communication skills

• Role modeling Be Creative!

Role ModelingThe Challenge...

• How does the teacher immerse himself or herself in the role without loosing the learner?

• Specifically, how does the teacher facilitate the learner’s involvement with the content, if the teacher is ‘on stage’?

TEACHER LEARNER

CONTENT

T-L-C EDUCATIONAL MODEL

TEACHER LEARNER

PATIENT

TEACHER IMMERSED IN CONTENT

Danger of role immersion- linksto learner weakened

Role ModelingThe Context

• Part of continuity experience?

• How is modeling linked to didactic session(s)

• Who are the learners?– ? Mixed skill levels or homogenous

• Special learning opportunities?– Unusual situations, patients in nursing home

Questions to ask...

Setting a theme• Useful especially if seeing patients in series• May link to didactic session, special learner

needs and learning opportunities• Assign learner tasks within a theme• Examples:

– “Why is this patient here?”– “Look at the walls and tabletops”– “What does home mean to this patient?”– “How do different confusional states differ?”

Before seeing the patient

• Reinforce theme, if present

• Collect data

• Set specific tasks-– That you wish to accomplish– Tasks for learners

The Patient Encounter

• Goal- immerse yourself totally in the relationship, but continue to involve the learner– Analogous to a good actor- must become the

role, but in a manner that allows the audience to see

• This so difficult- it’s a life-time practice

The Echo

• Definition: A verbal reflection of internal thought processes

• Method:– Explain what you are doing– Filter what you don’t want patient to hear– Interpret what you mean so patient/family can

understand

• Example: patient with red-eyes

The Lateral Pass

• Definition: A means of changing roles to facilitate new forms of interaction

• Method: make patient (or learner) the teacher

• Examples:– “You’re the one with pain, what can you teach

us about pain (or dying)”

After the Patient Encounter

• Opportunity to re-connect learner to content– “What questions do you have?”

• Opportunity to evaluate – “What did you see?”– “What was I trying to show when I…”

• Time to comment- fill in the blanks

• Time to reinforce/summarize

SUMMARYSUMMARY

• The nursing home is an excellent place for teaching knowledge and skills rarely taught elsewhere

• Teaching can be very rewarding and appreciated by physicians in training

• Doing the job well requires a solid knowledge base, planning and skill