1-week required rotation inPalliative (EOL) care

Frank A. Filipetto, DO and Lucia Beck Weiss, MSUMDNJ – SOM (Family Medicine)

Janet M. Lieto, DOSamaritan Hospice

Educational Objectives / Participant Outcomes

We hope to identify for you:

palliative care rotation components and learner competencies.the use of WebCT as a method of delivering and evaluating curriculum.the benefits of simulated exercises in enhancing communication skills surrounding end-of-life issues.strategies for collaboration with community and other health care providers and organizations. rotation outcomes.

Why an EOL Competency?

Physicians:Are poor prognosticators 1

Delay initiation of palliative care 2

Prolong/encourage futile care based on undue optimism 3

1. Christakis et al, BMJ, 2000 2. Support Trial, JAMA 1995 3. Murphy et al, NEJM 1994

Background

Funded by HRSA (AAU) grantOne week required rotation within Family Medicine clerkship year IVFollows or precedes a one week CPM rotationVariety of learning methodologiesCultural and Interdisciplinary competenciesCommunity resources (Hospice, funeral homes)

Palliative (EOL) Rotation Objectives

Students on this clinical rotation will be able to:

Define the concepts, goals and objectives of Palliative Care Medicine.

Understand the role of Hospice in delivering palliative care.

Know how to manage pain, vomiting, dyspnea, secretions, agitation, hiccoughs, depression and constipation.

Recognize prognostic signs and symptoms of illnesses necessitating institution of palliative care.

Understand the meaning of DNR/DNI, reasons for DNI order and alternatives to intubation, risks and benefits of CPR, risks and benefits of intubation, and how to discuss these issues with patients/family members.

Discuss end-of-life issues with patients and their families, notably Truth-Telling and Informed Consent.

Understand Interdisciplinary Team Work (IDTW) precepts.

Appreciate the role of culture on death and dying.

Access literature and Web-CT based resources to retrieve relevant information about Palliative Medicine.

Rotation Components

Orientation

On Line Pre/Post Test of Knowledge

15 WebCT Modules/Fast Facts (EPERC)*

Readings and written assignment

Home visits, Inpatient hospice, Interdisciplinary meetings, Funeral Director

Standardized Patient encounters

On Line Final Exam and evaluation

*End of Life/Palliative Education Resource Center- Med. College of WI

Faculty and Components 1 Week Palliative Care Rotation

Web-CT

Samaritan Hospice

House and Funeral home visits

Standardized Patient Encounters

Schedule for Palliative WeekMonday 8:00 AM Orientation and/or Pre-testMake Phone Calls to arrangement Funeral Home VisitsAfternoon – WebCT (must be reviewed for Tuesday)

Tuesday 9:00 AM Tuesday PMSamaritan Hospice In-patient Samaritan Hospice 5 Eves Drive, Virtua Memorial Hospital  Suite 300 175 Madison Avenue Marlton, NJ 08053 Mount Holly NJ, 08060

Wednesday Funeral Home Visit and complete written assignmentWeb-CT, Readings and Assignments

Thursday8:30 am Home Visits with Dr. Herring (or alternative

arrangements)PM Funeral Home Visits; Web-CT; Complete “Attitudes and

Concepts of Death and Dying” Worksheet Friday1:15 PM - Standardized Patient Cases

On-Line Course

Web-CT

Development of online courseLooked at existing resourcesEPERC – End of Life /Palliative Education

Resource Center – Med. College of WI http://www.eperc.mcw.edu/

Acquired curriculum including:15 introductory modules

PowerPoint presentations Fast Facts Evaluation Instruments

Modules

1. Overview-Dying-in-America  

2. Hospice

3. Breaking-Bad-News

4. Family-Conference

5. Culture-and-End-of-Life-Care

6. Treatment-Goals

7. DNR

8. Artificial-Nutrition

9. Depression

10. Constipation

11. Dyspnea- and Delirium

12. Nausea-and-Vomiting

13. Pain-Assessment

14. Pain-Drug-Therapy

15. Pain-or-Addiction

Let’s Visit the Website

www.umdnj.edu/webct

Links on Web-CT

Tests and Surveys

Slide Presentations and Fast Facts

Sample:

Treatment Goals

Tracking Tools

Instructor Tools

Evaluation Instruments

Pre-test - mean – 61.4%

Post-test - mean – 75.6%46 item instrument

Final Exam – mean 84.9%32 questions randomly generated by the

computer from a bank of 80 itemsStudent must score above 70% to pass

rotation

} 23% increase

Test Item Analysis

A detailed item analysis revealed: Items with high pre-test scores – 16 Items with significant improvement – 18 Items with low improvement – 12

Items needing improvement focused on patient autonomy, decision-making ability, power-of-attorney, and advanced directive.Items showing significant improvement focused on pain management and patient comfort issues.

Student Feedback – n=9278 students indicated that the rotation met its stated objectives

79 students indicated that the clinical experience is an effective way to learn about this subject.

72 students indicated that the on-line course is an effective way to present important information about this topic.

79 students indicated that the on-line course is user-friendly and easy to navigate.

80 students indicated that the content of this rotation was appropriate for my learning.

75 students indicated that their own pre-rotation perspectives on Chronic Pain and Palliative Care changed as a result of this rotation.

Student CommentsIt's good that we had this rotation as part of our curriculum because we probably would never learn this again.

You should give more time for the final exam, I felt a little rushed

thank you for sending us places where we were wanted...everywhere I went, people were pleasant - this is a rarity

The WebCT portion of the course and our orientation to the rotation where very well designed. Thank you for your hard work.

Clinical experience at the Hospice was excellent. I thought the visit to the Funeral homes were unnecessary.

I really liked the self-directed learning module for palliative care.

Funeral Home Assignment

Standardized Patient Encounters

CASE OVERVIEW You are a family physician about to see your patient of 5 years, Mr. Carl Wagner. You had been seeing him every year or two for checkups. You last saw him 6 months ago when he came in complaining of a chronic cough. A chest x-ray revealed a large apical tumor, All treatment options have been exhausted. He has been referred back to you by his oncologist for treatment to keep him comfortable. He told the nurse he has increasing pain, which is keeping him up at night.

CASE OVERVIEW You are the attending physician for Lloyd Jones, a 65 year old gentleman whose needle biopsy today revealed inoperable cancer. Your resident has already spoken to the daughter, Gwen Jones, and told her of her fathers’ poor prognosis with and without treatment. Ms. Jones has requested to see you ASAP, and you’ve heard that she is insisting that no one tell her father about his diagnosis. You are about to see her in a small hospital conference room to address her concerns.

Partnering with Samaritan Hospice

Partnering with Samaritan HospiceWhat makes it work

Regional leader and not-for-profit

30,000 families served since 1980

Service for more than 30,000 families since 1980

Clinical leadership: full time DO, MD, APN

Inpatient Unit housed in a hospital

Complementary Therapies

Partnering with Samaritan HospiceWhat makes it work

Samaritan Center for Grief SupportSpecialized programsTender HeartsJewish HospiceCatholic MinistryVeterans OutreachWound Care TeamPediatric Palliative CareTransitions (PreHospice Program)

Partnering with Samaritan HospiceWhat makes it work

Institute for Education and ResearchValues Evidence Based Medicine>300 professional and community

education program/yearPatient Reported Outcomes Measures

(PROM) in partnership with Hospice Pharmacia

Passionate staff who love to teach

Partnering with Samaritan HospiceStudents Experience

Interdisciplinary Team MeetingPhysicianNurses (RN, LPN)Social workerChaplainBereavementComplementary therapies

Partnering with Samaritan HospiceStudents Experience

Debriefing Students After TeamHistory of hospiceHospice regulationsHospice criteriaCertificationPhysician’s responsibilities’Hospice and subspecialties (THIS MEANS

YOU!!!)Answer all questions

Partnering with Samaritan HospiceStudents Experience: Inpatient Unit

Interdisciplinary Team Rounds

Hands on patient evaluations

Spiritual and emotional factors

Family concerns

Psychosocial factors

Samaritan Inpatient UnitAggressive Symptom ManagementPain-Pain-Pain

Dyspnea

Nausea and vomiting

Constipation

Delirium

Hiccups

Cachexia

Seizures

Anxiety

Depression

Muscle spasms

Insomnia

Agitation

Pain-Pain-Pain

Samaritan Inpatient UnitActively Dying Patients

Signs and symptoms

Management of patient

Terminal agitation

Dealing with families

Palliative sedation

Caring for staff

Questions

Thank you!