STATE OF THE DIVISION:An Update on the past, present & future of the DIVISION OF PALLIATIVE CARE

Jeff Myers MD, CCFP, MSEdW. Gifford-Jones Professorship in Pain and Palliative CareHead and Associate Professor - Division of Palliative Care, Department of Family and Community MedicineFaculty of Medicine, University of Toronto

DPC Grand Rounds June 14, 2012

DIVISION OF PALLIATIVE CAREWho are we?What does being a DPC Member mean?What do we do?Why do we matter?Where are we going?How will we get there?What can each of us do?

DPC: WHO ARE WE?

“The core purpose of the DPC is to create and support a community of learners, teachers, innovators, researchers and practitioners working together to improve the quality of palliative and end of life care for patients and their families.”

DPC Strategic Plan, 2009

The values serving to guide all DPC activities are:

Interprofessionalism CommunityInnovation Advocacy

DPC Strategic Plan, 2009

DPC: WHO ARE WE?

The largest academic palliative care division in Canada!!!

DPC: WHO ARE WE?

2002: Residency Program 2007: Formal status as an academic Division

(Head, Dr. Larry Librach, 2007-11)

2009: Inaugural Strategic Plan: Long Term VisionEvery health care professional trained

through the U of T will be able to demonstrate basic competencies in the provision of quality palliative and EOL care

DPC will be a leader in developing, measuring and teaching advanced

competencies in palliative care in Canada

DPC: WHO ARE WE?

Long Term VisionA robust and collaborative research program will

be credited with discoveries that challenge current best practice in care provision and

education and explore innovative interventions that improve the quality of palliative and EOL care

Professionals seeking a location for clinical practice, research and/or education in palliative care within an expansive, dynamic environment

will choose Toronto and the DFCM’s DPC

DPC: WHO ARE WE?

DPC: ORG STRUCTURE

DPC: COMMITTEE LEADS

CPD Lead: Monica Branigan RPD: Giovanna SirianniInterim RPD: James Downar Education Co-Leads: Anita Chakraborty &

Monica BraniganResearch Co-Leads: Amna Husain &

Paolo MazzottaAdmin Lead: Heather Huckfield

DPC: PROFESSION / DISCIPLINE LEADS

Social Work: Susan Blacker

Nursing: Sharon Reynolds

Pediatrics: Adam Rapaport

DPC: SITE REPS

Baycrest: Daphna GrossmanCVH: Manisha SharmaMarkham Stouffville: Gina YipMt Sinai: Russell GoldmanNYGH: Niren ShettyPMH: Julia Ridley Scarborough: Larry ZobermanSickKids: Adam Rapaport

DPC: SITE REPS

Southlake: Cindy SoSt. Joseph’s: Carol HughesSt. Michael’s: Ignazio LaDelfaSunnybrook: Dori SeccarecciaTEGH: Kevin WorkentinTGH/TWH: Sharon ReynoldsTrillium: Tony Hung

DPC: MEMBERS

Membership Assembly

Current composition:

Over 60 Faculty Members Over 60 Associate Members

FACULTY MEMBERSClinicians who have pursued and achieved a U of T faculty appointment

Available to all professionals who are members of a U of T affiliated institution and actively involved in palliative care and teaching, education, research, creative professional activity and/or leadership

DPC: WHAT DOES BEING A MEMBER MEAN?

ASSOCIATE MEMBERSClinicians without a formal clinical or faculty appointment with the U of T who have an interest and/or a clinical practice involving palliative care

DPC: WHAT DOES BEING A MEMBER MEAN?

DPC MEMBERSHIP: WHY?• Participate in DPC related activities, initiatives and

committees (eg. PD, teaching/education, research, clinical, operations, administrative, social networking)

• Contribute to building a sense of academic community • Be informed about DPC related activities and initiatives• Connect/collaborate with colleagues across the DPC• Cultivate a profession specific community • Gain exposure to and develop skills related to

professional and/or academic activities• Collaborate on profession specific projects/initiatives• Opportunities to explore formal and informal mentorship

WHAT DO WE DO?

DIVISION OF PALLIATIVE CARE

We Educate95% of DPC Members are involved in teaching and

education activities

DPC: WHAT DO WE DO?

Undergraduate MedicinePre-clerkship:

“Pain Week”; MMMD course “Approaching End Of Life”; ASCM

Clerkship: Anesthesia, General Surgery, Family Medicine, Transition to Residency, FMLE

DPC: WHAT DO WE DO?

Postgraduate Medicine

DPC: WHAT DO WE DO?

Postgraduate Medicine: Enhanced Skills• Clinical Palliative Care Enhanced Skills Program

St. Joseph’s Health Centre Site12 graduates since 2005

North York General Hospital Site*

• Conjoint Palliative Medicine Residency Program*Recently implemented

DPC: WHAT DO WE DO?

CONJOINT RESIDENCY PROGRAM

Annual Growth in # of Positions and Applicants

CONJOINT RESIDENCY PROGRAM:GRADUATES

DPC: WHAT DO WE DO?

CE & PD

We Educate - Innovations• Centre for IPE - Case Based Session• PGCoreEd• Social Work Interest Group - Susan Blacker• National Learner Assessment Collaborative• CVH/Trillium - collaboration with FHT (LEAP)• Collaboration with Cicely Saunders Institute:

Medical Student Exchange Fellowship (Dr. Robert Buckman)

DPC: WHAT DO WE DO?

We DiscoverOver 50 publications

in last five years

Dr. Amna Husain PI for CIHR Grant: Ranked #1

DPC: WHAT DO WE DO?

A few examples…

DPC: WHAT DO WE DO?

A few examples…

DPC: WHAT DO WE DO?

We Are Acknowledged2011 Undergraduate New Teacher Award: Dr. Jean Hudson2010 Helen P. Batty Award: Dr. James Meuser2010 DFCM Awards of Excellence: Dr. Monica Branigan2010 PD Program Excellence Award: Dr. Kevin Workentin2010 PD Program: Dr. Pauline Abrahams2009 John W. Bradley Educational Admin: Dr. Dori Seccareccia2009 Postgraduate Education Program: Dr. Leah Steinberg

A few examples…

DPC: WHAT DO WE DO?

We Are AcknowledgedSenior Promotion to the Rank of Associate Professor:

2012: Dr. Albert Kirsen & Dr. Vince Maida2011: Dr. Monica Branigan, Dr. Amna Husain & Dr. Jeff Myers2010: Dr. Jamie Meuser

A few examples…

DPC: WHAT DO WE DO?

WHY DO WE MATTER?

DIVISION OF PALLIATIVE CARE

DPC: WHY DO WE MATTER?

The MOH says so…

The care we provide makes a difference…

DPC: WHY DO WE MATTER?

We are catching on in other settings…

DPC: WHY DO WE MATTER?

Conclusions: “Our prospective study shows that dementia is a terminal illness and furthers our knowledge of the clinical complications characterizing its final stage.”

This was the first time this statement was made

We are catching on in other settings…

DPC: WHY DO WE MATTER?

“Classifying all seniors affected by advanced dementia as terminally ill…can become a

gateway to therapeutic neglect."

CLINICAL COURSE – DEMENTIALETTER TO THE EDITOR

We are catching on in other settings…and familiar challenges lie ahead

DPC: WHY DO WE MATTER?

A request was recently made of me to speak to the topic:

“How to initiate and have end-of-life discussions in the office for patients with palliative conditions?“

DPC: WHY DO WE MATTER?

A request was recently made of me to speak to the topic:

“How to initiate and have end-of-life discussions in the office for patients with palliative conditions?“

How might this be more precisely worded?

DPC: WHY DO WE MATTER?

A request was recently made of me to speak to the topic:

“How to initiate and have goals of care discussions in the office for patients with advanced and/or incurable“

DPC: WHY DO WE MATTER?

A request was recently made of me to speak to the topic:

“How to initiate and have goals of care discussions in the office for patients with advanced and/or incurable“Propose this to be a primary solution to effectively addressing the “tsunami of chronic disease”

DPC: WHY DO WE MATTER?

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Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.

Actual and Projected Deaths in Ontario: 1996-2036

WE ARE HERE!!!

WHERE ARE WE GOING?

DIVISION OF PALLIATIVE CARE

SUB-SPECIALTY STATUS• Currently, the RCPSC application process for

formal recognition of Palliative Medicine as a Sub-Specialty is in Stage 2 (Consultation Phase)

• New two-year medical training program• Routes of entry are IM, Neuro, Anesth for

Adults stream and Peds• Uncertain what the current one-year program

will evolve in to as per CFPC

DPC: WHERE ARE WE GOING?

• If/when a Sub-Specialty is formally created, the route of “practice eligibility” will likely be made available to physicians who have both completed the current one-year program and entered from a RCPSC specialty as well as current RCPSC members who maintain a clinical practice focused in Palliative Medicine

• Discussions at the CFPC are currently underway to determine if a certification and/or designation process will be instituted for the one-year program

DPC: WHERE ARE WE GOING?

• Based on what is determined, a practice eligible route is likely to be made available to current CFPC members who maintain a clinical practice focused in Palliative Medicine (with or without having completed the one-year training program)

• Family physicians who do not hold certification can acquire certification until December 31, 2012 via “Alternate Route to Certification” - see cfpc.ca

DPC: WHERE ARE WE GOING?

EOL CareHospice & Palliative Care

Curative / Remissive Therapy

Presentation Death

CG Support &Bereavement

Model of Collaborative or Shared Care

DPC: WHERE ARE WE GOING?

EOL CareHospice & Palliative Care

Curative / Remissive Therapy

Presentation Death

CG Support &Bereavement

Model of Collaborative or Shared Care Its time to move beyond this

DPC: WHERE ARE WE GOING?

Complex palliative care-related needs

Basic palliative care-related needsPt A

Pt C

Pt B

Pt D

Pt E

Illness trajectory EOL

Most will have needs requiring only basic PC skills (Pt A)

Others will occasionally require specialty level PC (Pts B, D)

A small number with highly complex needs will indefinitely require specialty level PC (Pts C, E)

LEVELS OF PALLIATIVE CARE

PROVISION OF PALLIATIVE CAREAcademic Mandate

Patient Volumes

Description of Patient

Needs

Levels of Care Expertise

Description of Provider Role

Care Setting

• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans

• Experts in PC; consults to secondary and primary level providers; Leaders in PC research & education

• All care settings require at least access to tertiary level expertise generally hospital based

• PC needs exceed those available from primary care;• Pt/families ability to cope is compromised

• Extensive PC knowledge in PC; model of care may be consult only to direct care; most often share care with primary team

• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)

• Largest group of patients;• Most needs met through primary care providers (i.e. non-PC specialists

• Basic or primary level PC related clinical skills (pain and Sx Mx; basic psycho-social care)

• All care settings

Tertiary Level

Secondary Level

PC Expertise

Primary LevelPC Expertise

Academic Mandate

Patient Volumes

Description of Patient

Needs

Levels of Care Expertise

Description of Provider Role

Care Setting

• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans

• Experts in PC; consults to secondary and primary level providers; Leaders in PC research & education

• All care settings require at least access to tertiary level expertise generally hospital based

• PC needs exceed those available from primary care;• Pt/families ability to cope is compromised

• Extensive PC knowledge in PC; model of care may be consult only to direct care; most often share care with primary team

• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)

• Largest group of patients;• Most needs met through primary care providers (i.e. non-PC specialists

• Basic or primary level PC related clinical skills (pain and Sx Mx; basic psycho-social care)

• All care settings

Tertiary Level

Secondary Level

PC Expertise

Primary LevelPC Expertise

PROVISION OF PALLIATIVE CARE

WHERE ARE WE GOING AND HOW WILL WE GET THERE?

OUR initial strategy will be to BUILD CAPACITY

DIVISION OF PALLIATIVE CARE

DPC: HOW WILL WE GET THERE?

It should not be advocacy for earlier integration of the PC field

in the illness trajectory…

It should be advocacy for earlier integration of both PC philosophy

and PC-related clinical skills

DPC: HOW WILL WE GET THERE?

If oncology has just recently integrated palliative care-related clinical skills in to their training programs, what about every other illness known to be incurable and the IP teams who care for

them?

…CHF, COPD, Dementia, ND, CKD, cirrhosis, metabolic disorders…

DPC: HOW WILL WE GET THERE?

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1997-98

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2011/2012

2012/2013

2013/2014

2014/2015

2015/2016

2016/2017

2017/2018

2018/2019

2019/2020

2020/2021

2021/2022

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20

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100

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80 80 80 81 81 81 83 84 85 84 8689

92 94 96 98 100102104106108110112114116118120122124127129131134137140

143145

148152

Num

ber o

f Dea

ths (

1000

's)

Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.

Actual and Projected Deaths in Ontario: 1996-2036

WE ARE HERE!!!

HOW WILL WE BUILD CAPACITY?

INTEGRATION EDUCATION

COMMUNITY BUILDING

DPC: HOW WILL WE GET THERE?

DPC: INTEGRATION

BEGIN WITH DFCM• DPC Head: Site Visits • Faculty Appointments: Collaborative

Model with Site Chiefs• “DPC: A Resource for DFCM Faculty”

Next four slides outlines possible elements • “DFCM Site Integration Tool Kit”

DPC: INTEGRATION

DFCM Site Integration Tool Kit • Examples of possible standard presentations

• “The DPC As A Resource to the DFCM: How to Have a Discussion with the DFCM Chief”

• “Strategies for Teaching Your Family Medicine Colleagues”

• “The Palliative Care You’re Providing But May Not Know It: Building Capacity Among Family MDs”

• As well, presentations on topics from brochure

DPC: EDUCATIONRepository of resources:• Resources for community building through

collaborations and sharing• Resources for Learners• Resources for Teachers

undergrad, postgrad, IPE, CE, other prof• Resources for Researchers• Resources for Leaders• Patient and Family Education Resources

DPC: COMMUNITY BUILDING

• DPC Face to Face Event - Sept/Oct 2012 • DPC New Member Orientation • DPC FAQs (What, Who, Where, Why, How)• Value-add vehicle supporting collaboration

DPC: WHAT CAN EACH OF US DO?

THIS IS A CALL TO ACTION Each of us MUST consider

ourselves an essential resource Every professional interaction

MUST have two components: CLINICAL AND EDUCATIONAL

For EVERY professional interaction:• Contribute thoughtfully• Be willing to teach• Be precise & vigilant with your

words

DPC: WHAT CAN EACH OF US DO?

Each of us MUST view ourselves as leaders, ambassadors & educators as well as be thoughtful in:• How we contribute eg. discussions re: “Care

delivery models” • How we view consultations and referrals as

more than JUST patient/family care but as opportunities to educate our colleagues “What can I teach, to whom, how and will my response differ next time?”

DPC: WHAT CAN EACH OF US DO?

With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…

• “What do you mean by‘terminal’?”• “What do you mean by‘palliative’?”

“Oh you mean her illness is incurable.” “What’s her performance status and level of function as well as goals for her care?”

DPC: PRECISION WITH OUR WORDS

With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…

“Jeff, can I talk to you about a referral we have made to pain clinic?”

“Nope. But happy to speak about a referral made to palliative care clinic. Did you tell the pt she was being seen in palliative care clinic?”

DPC: PRECISION WITH OUR WORDS

DPC: OUR TIME IS NOW!!!

Who are we?What does being a DPC Member mean?What do we do?Why do we matter?Where are we going?How will we get there?What can each of us do?

jeff.myers@sunnybrook.ca