clinical experience in hospice and palliative medicine for clinicians in practice

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JOURNAL OF PALLIATIVE MEDICINE Volume 1, Number 3,1998 Mary Ann Liebert, Inc. Clinical Experience in Hospice and Palliative Medicine for Clinicians in Practice CHARLES F. VON GUNTEN, M.D., Ph.D., JEANNE MARTINEZ, R.N., M.P.H., KATHY J. NEELY, M.D., MARTHA TWADDLE, M.D., and MICHAEL PREODOR, M.D. ABSTRACT Many healthcare professionals already in practice have identified their need to pursue fur- ther practical training in the provision of hospice and palliative care. We began offering a 1- week clinical experience to physicians, nurses, pharmacists, social workers, and chaplains in the summer of 1995. As of October 1,1997, there have been 190 requests for application ma- terials from individuals in more than 22 states, as well as from Singapore and Uganda. Thirty- five individuals completed visits by October 31,1997; 17 nurses, 16 physicians, 1 psycholo- gist, and 1 chaplain. Although all are working in areas related to palliative care, 57% (20 of 35) were not currently working for a hospice program. A 25-question examination was ad- ministered as a needs-assessment test. Overall they scored 75% correct. They did especially poorly on questions related to dosing of opioids, assessment of pain, and prognosis in AIDS. They completed a videotaped interview with a standardized patient focusing on skills in dis- cussing a terminal prognosis, "do not resuscitate" (DNR) status, and hospice referral. They evaluated the entire educational experience with a self-report at the end of their visit using a Likert Scale with values of 1 to 5. To the statement "I achieved the specific goals which I set for myself," the average score was 4.6 (range 1-5). To the statement "The experience was worth the time and effort," the average score was 4.9. To the statement "I would recommend this experience to others," the average score was 4.9. The evaluation was repeated 6 months after the visit with similar scores. In addition, to the statement "My current efforts are help- ing to change the way dying patients and their families are cared for in the broader environ- ment in which I work," the average score was 4.9 (range 4-5). We conclude that this is a suc- cessful program of clinical exposure to hospice and palliative medicine for clinicians in practice. INTRODUCTION ther hospice nor palliative care is a significant part of health professional education. Yet, in T HE INTERDISCIPLINARY CARE OF PATIENTS and its decisions regarding the lack of a constitu- families with advanced progressive dis- tionally based right to die, the U.S. Supreme ease where the prognosis is limited and the Court did find that Americans should expect focus is the relief of suffering is called "hos- palliative care. 1 In its report issued in 1997, 2 pice" or "palliative care." Unfortunately, nei- the Institute of Medicine indicated that pal- Hospice and Palliative Medicine, Northwestern University Medical School, Chicago, Illinois. 249

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Page 1: Clinical Experience in Hospice and Palliative Medicine for Clinicians in Practice

JOURNAL OF PALLIATIVE MEDICINEVolume 1, Number 3,1998Mary Ann Liebert, Inc.

Clinical Experience in Hospice and Palliative Medicinefor Clinicians in Practice

CHARLES F. VON GUNTEN, M.D., Ph.D., JEANNE MARTINEZ, R.N., M.P.H.,KATHY J. NEELY, M.D., MARTHA TWADDLE, M.D., and MICHAEL PREODOR, M.D.

ABSTRACT

Many healthcare professionals already in practice have identified their need to pursue fur-ther practical training in the provision of hospice and palliative care. We began offering a 1-week clinical experience to physicians, nurses, pharmacists, social workers, and chaplains inthe summer of 1995. As of October 1,1997, there have been 190 requests for application ma-terials from individuals in more than 22 states, as well as from Singapore and Uganda. Thirty-five individuals completed visits by October 31,1997; 17 nurses, 16 physicians, 1 psycholo-gist, and 1 chaplain. Although all are working in areas related to palliative care, 57% (20 of35) were not currently working for a hospice program. A 25-question examination was ad-ministered as a needs-assessment test. Overall they scored 75% correct. They did especiallypoorly on questions related to dosing of opioids, assessment of pain, and prognosis in AIDS.They completed a videotaped interview with a standardized patient focusing on skills in dis-cussing a terminal prognosis, "do not resuscitate" (DNR) status, and hospice referral. Theyevaluated the entire educational experience with a self-report at the end of their visit usinga Likert Scale with values of 1 to 5. To the statement "I achieved the specific goals which Iset for myself," the average score was 4.6 (range 1-5). To the statement "The experience wasworth the time and effort," the average score was 4.9. To the statement "I would recommendthis experience to others," the average score was 4.9. The evaluation was repeated 6 monthsafter the visit with similar scores. In addition, to the statement "My current efforts are help-ing to change the way dying patients and their families are cared for in the broader environ-ment in which I work," the average score was 4.9 (range 4-5). We conclude that this is a suc-cessful program of clinical exposure to hospice and palliative medicine for clinicians inpractice.

INTRODUCTION ther hospice nor palliative care is a significantpart of health professional education. Yet, in

THE INTERDISCIPLINARY CARE OF PATIENTS and its decisions regarding the lack of a constitu-

families with advanced progressive dis- tionally based right to die, the U.S. Supremeease where the prognosis is limited and the Court did find that Americans should expectfocus is the relief of suffering is called "hos- palliative care.1 In its report issued in 1997,2

pice" or "palliative care." Unfortunately, nei- the Institute of Medicine indicated that pal-

Hospice and Palliative Medicine, Northwestern University Medical School, Chicago, Illinois.

249

Page 2: Clinical Experience in Hospice and Palliative Medicine for Clinicians in Practice

250 VON GUNTEN ET AL.

liative care should be incorporated into the work students, nursing students, and seminar-training and clinical practice of physicians ians in hospice and palliative medicine haveand other allied healthcare disciplines. This manifested this. The focus of the collaborationimplies that a formal educational program also has expanded past cancer to include all pa-that establishes a firm knowledge base of tients with advanced illness for whom the re-these important issues should occur early in lief of suffering is the primary goal of therapy,the educational process and be reinforced An area of expertise within the program hasthroughout undergraduate, postgraduate been the palliative care of patients with AIDS,training, and clinical practice. Only an inte- Since the beginning of the epidemic, the Com-grated and coordinated program of education prehensive AIDS Program at Northwesternin hospice and palliative medicine will shape and the Hospice/Palliative Care Program havethe knowledge, attitudes, skills, and practice worked together closely. Consequently, the fac-of healthcare professionals. It is the purpose ulty has broad experience in the palliative careof this article to describe one element of such issues that are unique to AIDS. Visiting schol-an academic program in hospice and pallia- ars are routinely exposed to the palliative caretive medicine at Northwestern University of AIDS patients and may elect for special fo-Medical School (NUMS). cus in this area.

Many healthcare professionals already in As the collaboration between these programspractice have identified their need to pursue has developed and expanded, the collabora-further practical training in the provision of tion between the university and the hospicehospice and palliative care (personal commu- programs for the purposes of education and re-nication). Although there now exists a broadly search has extended to two additional corn-accepted body of literature describing the ele- munity hospice programs. The clinical re-ments of good care, there are few places in the sources available to the visiting scholars areUnited States where professionals can go for shown in Table 1. The visiting scholar identi-practical training in this area (personal com- fies those areas in which the scholar would likemunication). Therefore, the Roxane Visiting to improve knowledge and skills and sets goalsScholar Program was established as a continu- to accomplish during the experience. A pro-ing medical education program with two pur-poses in mind:

TABLE 1. CLINICAL RESOURCES

• To provide a practical educational experi- Palliative Medicine Consultation Service atence in hospice /palliative medicine to Northwestern Memorial Hospital (700-bed tertiaryhealthcare professionals. ™re Prin

fciPal ^ i 1 * ? h° sP i t a l o f Northwestern

r University Medical School).• To tailor the educational experience to the inpatient Hospice/Palliative Care Unit at Northwestern

self-identified needs of the visiting scholar. Memorial Hospital, opened in 1987 (12-bed hospitalunit for the acute symptomatic care of patients in the

_ „ . . . . r TT , , , „ , . context of Hospice/Palliative Medicine).The Division of Hematology/Oncology and Home Hospice Program of Northwestern Memorialthe Robert H. Lurie Cancer Center of North- Hospital, established in 1982 (home hospice programwestern University was chosen as the site for for patients within the city limits of Chicago, 400this program because of the depth and breadth Comprehens^AIDS Program of Northwesternof experiences available to visiting scholars. Memorial Hospital (inpatient consultation service,The Division and the Cancer Center have iden- outpatient clinic, and home care services).tified the relief of suffering as a priority. Con- H o r i z ™ H° sP i c e (u^ban community hospice with

& \ } significant percentage of AIDS patients including asequently, they have fostered close relation- residential home for AIDS patients, in addition toships between the University and the Hospice patients at home, 500 patients/year).Program of Northwestern Memorial Hospital. P a l l i a t i v e Care Center of the North Shore (suburban_, . , . i • i i i i , „ _ community agency with hospice and home careThis relationship has developed over the 15 divisions with significant percentage of nursingyears this hospice program has been in exis- home patients, in addition to patients at home,tence. Collaboration in the practical education 14"bed inpatient hospice unit Average census 600

c j - i . j . t . CL c n - i patients/year in the hospice division),

of medical students, housestaff, fellows, social _ _ -

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CLINICAL EXPERIENCE IN HOSPICE AND PALLIATIVE MEDICINE 251

gram is then specifically designed to accom-plish those goals prior to the visit.

VISITING SCHOLAR PROGRAM

The educational opportunity was advertisedwith a flyer at the annual meeting of the Acad-emy of Hospice Physicians and Academy ofHospice Nurses as well as notices that wereprinted in the Network Newsletter published byMemorial Sloan-Kettering Cancer Center andthe Palliative Care Letter published by RoxaneLaboratories, Inc. A flyer to all members of theAmerican Academy of Hospice Physicians wassent in February 1997.

Interested persons, including physicians,nurses, pharamcists, social workers, and chap-lains, may request an application from the pro-gram. The application asks for informationabout the applicant's current work and specificeducational needs that the applicant would liketo address during the visit. A curriculum vitaeis requested. The program coordinator andprogram director review applications and ex-tend invitations to visit.

A letter is sent extending an invitation tovisit. In general, a scholar is invited to spendlweek with the program, and one or two vis-iting scholars are accommodated per week. Theopportunity is offered once each month for 11months of the year.

Upon receipt of an applicant's acceptance ofthe offer to visit, the secretary for the programcontacts the applicant directly to make a firmcommitment as to dates and to arrange hoteland travel arrangements, which are paid for bythe program. A stay over Saturday night is ex-pected due to airfare considerations.

In general, the day extends from 8:00 A.M. to5:00 P.M. The period begins with an orientationby the Program Director or associate. Based onthe needs of the scholar, the educational activ-ities are selected from the list shown in Table2. For those clinicians without familiarity withhospice care, home visits and sessions on grief,bereavement, and spiritual issues are included.Interdisciplinary staff (such as nurses, socialworkers, chaplains, and/or the bereavementcoordinator) from the program conduct thesesessions.

TABLE 2. POSSIBLE EDUCATIONAL ACTIVITIES

Multidisciplinary home hospice team roundsMultidisciplinary inpatient hospice team roundsMultidisciplinary inpatient palliative medicine

consultation roundsMultidisciplinary rounds with inpatient HIV serviceIndividual sessions with

Program director (Medical Director NMH Hospice)Nurse leader (NMH Hospice)Palliative medicine consultation nurseNMH hospice social workerNMH Coordinator of Bereavement and VolunteersNMH analgesic dosing pharmacistNMH hospice chaplainPalliative medicine fellow (rotating from

Hematology/Oncology)HIV nurse specialist, NMHHIV clinic staff, NMHHIV physician specialists, NMH

Home visits with hospice physician or home hospicenurse

Medical Director, Horizon Hospice (urban communityhospice)

Medical Director, Hospice of the North Shore(suburban community hospice)

Various members of community hospice programs asneeded

Chief, Hematology/Oncology, Northwestern UniversityMedical School

Director, Cancer Center, Northwestern UniversityAny scheduled conferences in the Divisions of

Hematoloty/Oncology or HIV infectious disease.

A 25-question test is administered at the be-ginning of the rotation to serve as a needsassessment. We used several versions of thismultiple-choice test. The tests were not admin-istered in a pretest/posttest fashion because ofthe short time of the visit and the variety of ex-periences that constituted each scholar's expe-rience during the week.

The last 17 scholars were administered thesame version of a 25-item test developed byDavid Weissman, Janet Abraham, and Charlesvon Gunten. A manuscript describing the de-velopment and validation of the instrument isin preparation.

All scholars are asked to complete a video-taped interview with a standardized patient fo-cusing on communication about bad news andend-of-life decision making. The standardizedpatient is drawn from the pool of standardizedpatients trained by the Office of Medical Edu-cation at Northwestern University MedicalSchool for participation in the undergraduate

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252 VON GUNTEN ET AL.

medical student curriculum in communication.The following scenario was used.

Standardized patient biography given to vis-iting scholar: Mr(s). P is a patient who wasdiagnosed with Dukes D colon cancermetastatic to liver 2 years ago. The pri-mary lesion was resected, and the patientwas referred to a medical oncologist. Thepatient was treated with a course of fluo-rouracil and leukovorin on a bolus sched-ule for 6 months. Computed tomography(CT) scan of the abdomen revealed pro-gressive disease. The patient declined in-vestigational therapy but pursued acourse of continuous-infusion fluorouracilas an outpatient. The overall course hasbeen relatively uncomplicated. The pa-tient has completed 6 months of this ther-apy. A CT scan was recently performed onan outpatient basis. The patient has madean appointment because of progressive fa-tigue. The patient does not know the re-sults of the CT scan. At today's interview,the patient describes progressive fatigueand some right upper quadrant discom-fort. The examination shows increased ab-dominal girth and a palpable nodularliver. Percussion for shifting dullness isequivocal. The CT scan is reported toshow progressive liver disease. The video-taped interview begins when the clinicianinvites the patient into the consultationroom. The clinician is asked to accomplishthree goals: (1) Discuss the results of theexamination and CT scan, (2) discuss theDNR status, and (3) clarify future patientgoals and introduce the hospice concept.Biography for standardized patient: You werediagnosed with colon cancer 2 years ago.You had experienced occasional bloodystools and constipation for some time be-fore that but had otherwise been healthy.At the time of the operation, it was notedto have spread to the liver. You were re-ferred to an oncologist who treated youwith chemotherapy as an outpatient in-volving injections into the veins each dayfor a week out of every month for 6months. Side effects were sore mouth, di-arrhea and fatigue. When the tumors in

your liver did not go away, you declinedto undergo experimental therapy. Rather,you elected to have a permanent catheterplaced in your chest, and additionalchemotherapy was given continuously to"bathe the cancer" in the medicine for 4out of every 6 weeks.It is now 6 months into this therapy. Youhave recently had another CT scan to seehow the tumors in your liver are doing.The chemotherapy is currently stopped.You have not seen your oncologist, but hehas not generally been very forthcomingor given you satisfactory answers to yourquestions. You have scheduled an ap-pointment to discuss your overall condi-tion, with particular concern about pro-gressive fatigue. At the present time youare finding it difficult to continue workingas a stockroom clerk. You are married withtwo young children. Your spouse is sup-portive, but not present today. You are notparticularly interested in high-risk, low-yield medical care. You are aware thatyour cancer is not curable, but don't reallyknow enough details about your presentcondition to make decisions about the fu-ture. You have thought some about dyingfrom this cancer, but have never discussedthis with a clinician. You have had a highschool education. As a patient your goalsare to learn: (1) What's happening with mycancer? (2) Why am I tired? and (3) Whatshould I do now?

The videotape is reviewed with the clinicianand evaluated using the SEGUE criteria devel-oped and validated by Gregory Makoul, Ph.D.,at Northwestern University Medicine School(personal communication). The 32-item check-list evaluates the clinician in five areas: settingthe stage, eliciting information, giving infor-mation, understanding the patient's perspec-tive, and ending the visit. Additional aspectsevaluated were (1) How well were advance di-rectives discussed, including DNR status? and(2) How were future options, including Hos-pice referral, discussed? The SEGUE instru-ment was not given to the trainees prior to theinterview.

To evaluate the entire educational experi-

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CLINICAL EXPERIENCE IN HOSPICE AND PALLIATIVE MEDICINE 253

ence, participants were asked to complete a tions. When asked how soon after a dose ofself-report form at the end of their visit and immediate-release oral morphine that a patientagain at 6 months after the visit. They were should be reassessed to determine maximalasked to rate their response to three statements analgesic effect, only 29% indicated the correctusing a numerical scale of 1 to 5, where 1 = response of 30 to 60 minutes. When asked thestrongly disagree, 2 = disagree, 3 = neutral, appropriate dose of breakthrough (rescue)4 = agree, and 5 = strongly agree. Statements medication (such as short-acting morphine forwere: (1) "I achieved the specific goals which I a patient on sustained-release morphine), onlyset for myself as a visiting scholar", (2) The ex- 53% indicated the correct response of 10% toperience was worth the time and effort", and 20% of the total daily sustained-release dose.(3) "I would recommend this experience to oth- When asked what was most worrisome in aers." Six months after their experience, they lung cancer patient with 4 weeks of increasingwere mailed a second survey asking them to back pain in the region of an abnormal plainrate their responses to the same three state- spine radiograph (lytic or blastic), only 47%ments. Additionally, they were asked to rate correctly identified an epidural metastasis withtheir response to a fourth statement, "My cur- or without spinal cord compression. Whenrent efforts are helping to change the way dy- asked when therapeutic analgesic levels shoulding patients and their families are cared for in be expected with transdermal fentanyl, onlythe broader environment in which I work." 53% correctly identified 12 to 24 hours. WhenWith both evaluations, they were asked to re- asked about a list of predictors of prognosis forspond to three open-ended questions: (1) patients with AIDS, only 29% identified that"What were the best aspects of the program? the T4 helper count was not useful in deter-(2) "What were the worst aspects of the pro- mining prognosis.gram? and (3) What changes would you rec- A detailed analysis of the videotapes usingommend? the SEGUE instrument, including those with

resident training in internal medicine, is inprogress in concert with the Office of Medical

EVALUATION Education and the Program in Communicationfor medical students. A general evaluation of

As of October 1, 1997, there have been 190 the videotaped interview with the visitingrequests for application materials from indi- scholars demonstrated good facility with inter-viduals in more than 22 states in the United viewing by all of the visiting scholars. Only twoStates, as well as from Singapore and Uganda, scholars declined to do the exercise. What wasFifty-two completed applications were re- apparent was the variety of interviewing stylesceived by the same date. Thirty-five healthcare used. The focus of the review with the visitingprofessionals completed visits by October 31, scholar was to identify areas of strength and1997: 17 nurses, 16 physicians, 1 psychologist, area where other techniques and approachesand 1 chaplain. Although all are working in ar- might be helpful.eas related to palliative care, 57% (20 of 35) Thirty-three (94%) self-report evaluationswere not currently working for a hospice pro- were available for analysis. To the statement "Igram at the time of their experience. All came achieved the specific goals which I set for my-for a period of 1 week, with the exception of self as a visiting scholar," the average score wasone local physician who elected to participate 4.6 (range 1-5). To the statement "The experi-on single days spread over several months. ence was worth the time and effort," the aver-

Overall, the scholars correctly answered 75% age score was 4.9 (range 4-5). To the statementof the initial needs assessment questions. This "I would recommend this experience to oth-score is essentially the same as that achieved ers," the average score was 4.9 (range 4-5).by residents in their second or third year of in- Responses varied to the three open-endedternal medicine training taking the same ex- statements. When asked when the best part ofamination (personal communication). The the experience was, all wrote copious corn-scholars did particularly poorly on five ques- ments. Common themes were the personal at-

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254 VON GUNTEN ET AL.

tention and time with practicing clinicians, ex-periencing new or different models of pallia-tive care delivery, and the diversity of experi-ences.

When asked what the worst part of the ex-perience was, many wrote "nothing" or left thespace blank. Some remarked on the desire tohave more time in the program. When askedwhat they would recommend as changes in theprogram, the majority wrote "nothing."

A summary, as of October 31,1997, of the 6-month self-report evaluations is as follows. Tothe statement "I achieved the specific goalswhich I set for myself as a visiting scholar," theaverage score was 4.9 (range 4-5). To the state-ment "The experience was worth the time andeffort," the average score was 5.0. To the state-ment "I would recommend this experience toothers," the average score was 5.0 To the fourthadditional statement, "My current efforts arehelping to change the way dying patients andtheir families are cared for in the broader en-vironment in which I work," the score was 4.9(range 4-5). We did not ask for specific detailsabout just what this work entailed.

DISCUSSION

The response to this program indicates thatthere is strong interest in further education inhospice and palliative medicine expressed byphysicians, nurses, and other healthcare pro-viders. The overall volume of inquiries is im-pressive in light of the relatively modest effortsto advertise its existence. The results of theevaluation indicate that participants find theexperience valuable, even in the short periodof a week.

There are significant limitations to the pres-ent study. The evaluation relies heavily on self-evaluation by participants who elected to par-ticipate. Objective evaluations of changes inknowledge and behavior were not includeddue to the diversity of trainees and the shortduration of the experience. Further evaluationof this model should include such objectivemeasures.

There is a remarkable paucity of descriptionsof similar clinical educational programs in pal-liative care for clinicians in practice in the lit-

erature. Our findings are similar to models thathave been piloted in other settings. Kristjansonet al evaluated a 2-week program of on-sitelearning for teams of caregivers from ruralManitoba at a palliative care center.3 Using aset of evaluation tools administered 2 weeksbefore the experience, at the completion, and 3months following completion, they demon-strated a small but sustained improvement inknowledge. Using actual chart audits, the in-vestigators were able to demonstrate some im-provements as well.

The significance of the present study lies incharting future options for education of clini-cians in hospice and palliative medicine. As themembers of the Committee on End-of-Life is-sues of the Institute of Medicine observed,everyone needs education.1 Because this areahas been neglected in medical education, a sub-stantial number of people who are already inpractice need additional training. Providingthis training presents a particular challenge inthat good clinical education involves directclinical contact with patients in the context ofsupervision by an experienced clinician. Ap-proximating traditional residency or fellow-ship training for the thousands of physiciansand other healthcare providers in practice whoneed additional education in this area is notpractical. It may come to pass that hospice andpalliative care becomes well integrated intograduate and postgraduate education pro-grams. In the United Kingdom, where pallia-tive medicine has been a recognized specialtysince 1987, there is a 4-year postgraduate train-ing program that is required for specialty sta-tus.4 It is not yet clear if such training programswill develop in the United States. Even if thatoccurs, it will take several generations for allclinicians working in the field to have passedthrough such programs.

This raises the question about how best toprovide education to those who are already inpractice and want more education. Althoughnumerous courses and symposia related to hos-pice and palliative care are held each year, it isunknown if such courses have a significant im-pact on actual clinical behavior. Certainly, suchcourses have not been effective in changingcancer pain management.5

One way is to combine individual learning

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CLINICAL EXPERIENCE IN HOSPICE AND PALLIATIVE MEDICINE 255

at a distance with short exposures to patientsat a clinical center of hospice and palliativecare.4 The present study suggests that evenquite short exposures may accomplish the goalof stimulating students to learn. Janjan et al.have reported that improvements in cancerpain management are maintained after inter-action with role models.6 The present studymight serve as the basis for a larger trial of ed-ucation where trainees are asked to work theirway through didactic material sent to them(such as the UNIPACs produced by the Amer-ican Academy of Hospice and Palliative Med-icine)/ followed by, or interspersed with, peri-ods of exposure to a clinical environment suchas the one described. The questions raised areinteresting: What elements of a clinical experi-ence are most effective? What is the minimumthat a trainee should experience? How manytimes should the trainee be exposed to a clini-cal environment? Should such a clinical expe-rience precede home study or only follow in-dividual work at home? What evaluation toolswould be most accurate in assessing the valueof the experience? Could a program of such adesign be the basis for fellowship training re-sulting in specialty recognition? The AmericanBoard of Hospice and Palliative Medicine inGainesville Florida, was established to recog-nize added qualifications in hospice and pal-liative medicine in 1995. The Board expresslyacknowledged that the knowledge base and re-quirements for evidence of training wouldlikely increase with time. It is an open questionto what degree accredited training should pre-cede such certification. Certainly recognitionby the American Board of Medical Specialties,or any of its constitutive boards, will dependon established and accredited training pro-grams.

Much remains to be done. The field of pal-liative medicine is in its adolescence in termsof establishing its principles and standards ofpractice. To be taken seriously, and to becomean integral part of medical care and medicaltraining, these steps must be taken. We specu-late that programs such as that described here

may prove to be an important component ofprograms of education in Hospice and Pallia-tive Medicine in the United States.

ACKNOWLEDGMENTS

We thank Roxane Laboratories, Inc., for anannual unrestricted grant in support of thisproject. Dr. von Gunten received support fromthe Open Society Institute's Project on Death inAmerica as a Faculty Scholar. We thank GloriaMathis for help in preparing the manuscript,and the staffs and patients of the hospices fortheir contribution to the program.

REFERENCES

1. Burt R: The Supreme Court speaks: not assisted sui-cide but a constitutional right to palliative care. N EnglJ Med 1997;337:1234-1236.

2. Institute of Medicine, Committee on Care at the Endof Life: Approaching Death: Improving Care at the Endof Life. Washington, DC: National Academy Press,1997.

3. Kristjanson L, Dudgeon D, Nelson F, Henteleff P, Bal-neaves L: Evaluation of an interdisciplinary trainingprogram in palliative care: addressing the needs ofrural and northern communities. J Palliative Care1997;13:5-12.

4. Doyle D: Palliative medicine training for physicians. JNeurol 1997;244(Suppl 4):26-29.

5. Weissman DE: Cancer pain education for physician inpractice: establishing a new paradigm. J Pain Symp-tom Manage 1996;12:364-371.

6. Janjan NA, Martin CG, Payne R, Dahl JL, WeissmanDE, Hill CS: Teaching cancer pain management: dura-bility of educational effects of a role model program.Cancer 1996;77:996-1001.

7. American Academy of Hospice and Palliative Medi-cine: UNIPACs: Hospice/Palliative Care Training forPhysicians, a self-study program. Reston, VA.

Address reprint requests to:Charles F. von Gunten, M.D., Ph.D.

Hospice and Palliative MedicineNorthwestern University Medical School

303 E. Chicago Avenue, Passavant 9EChicago, IL 60611