palliative care education where are we going? david e. weissman, md palliative care leadership...
TRANSCRIPT
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