PALLIATIVE CARE EDUCATION Where are we going? David E. Weissman, MD Palliative Care Leadership Center Medical 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 disease Hospice Presentation Therapies to relieve suffering and/or improve quality of life Bereavement Care 6mDeath

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:

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:

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 Penetration Palliative Care Mandatory Rotation 5 (4%) Part of Req. Course110 (88%) Separate Elective 32 (25%) Part of Elective 42 (34%) Other 14 (11%) AAMC 2001;

Medical College of Wisconsin Medical 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 Medicine92% Emergency Medicine78% Pediatrics74% Surgery65% 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 ( ) 12 month project to integrate an EOL curriculum * Funded by Robert Wood Johnson Foundation

% of Programs with Required End-of-Life Education

% 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: Medical Students

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 ( ) 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

Mean Self Confidence 26 EOL Clinical Tasks

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

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, 1 st 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 :

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 network Downloadable to PDA Available at EPERC ( 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 EPERC

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) 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 Teaching What do we know?

tension Much of EOL clinical learning occurs in the setting of educational 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, 1 st 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 Benchmarking Project

Key Performance Measure Aggregat e Average Pain assessment within 48 hours of admission96.2% Use of a numeric scale to assess pain78.1% Pain relief or reduction within 48 hours of admission76.0% Bowel regimen ordered with opioid therapy order58.6% Dyspnea assessment within 48 hours of admission91.3% 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 admission39.4% 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 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 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 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 disease Hospice Presentation Therapies to relieve suffering and/or improve quality of life Bereavement Care 6mDeath

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

Palliative Care Leadership Centers Medical College of Wisconsin Milwaukee, WI Fairview Health Services Minneapolis, MN Massey Cancer Center of the VCU Medical Center Richmond, VA Mount Carmel Health System Palliative Care Service Columbus, OH Palliative Care Center of the Bluegrass Lexington, KY University of California San Francisco, CA