A syllabus for fellowship education in palliative medicine

Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.     

The business of palliative medicine--Part 3: The development of a palliative medicine program in an academic medical center

Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.     

The business of palliative medicine--part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center

In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.     

Acute inpatient palliative medicine in a cancer center: clinical problems and medical interventions--a prospective study

The clinical characteristics and medical interventions of the 100 consecutive cancer admissions to the acute care inpatient palliative medicine unit at the Cleveland Clinic for 2 months are described. Median age was 62 years (range, 31 to 92 years). The male-female ratio was 1:1. Most admissions were referred by hematology-oncology and had prior antineoplastic therapy. Reasons for admission were symptom control and cancer-related complications. Patients underwent invasive diagnostic and therapeutic procedures, hydration, transfusions, radiation, or chemotherapy, or a combination, during their admission. Most were discharged home with hospice care or had outpatient clinic follow-up. The mortality rate was 20%. Aggressive multidisciplinary management of symptoms, disease complications, comorbid conditions, and psychosocial problems were provided. Palliative medicine physicians provided continuity of care in the outpatient clinic and at home. An acute inpatient palliative medicine unit within a tertiary level medical center has a definable and important role in comprehensive cancer care.     

The business of palliative medicine - part 5: service utilization in a comprehensive integrated program

The aim of palliative medicine is to provide multidisciplinary comprehensive care in advanced illness. Patient and family utilization of various product service lines offered by the Harry R Horvitz Center for Palliative Medicine at the Cleveland Clinic Foundation was studied. Newly referred patients were followed up prospectively until 85% had either died or been lost to follow-up. Demographic, clinical, and referral data were recorded; subsequent product service line utilization was updated daily. The total study period was 171 days, and 238 patients entered. Acute care inpatient unit, outpatient clinic visits, and 24-hour phone contacts were the most frequently used product service lines. Patients had a median of 3 contacts (range, 1 to 27) with individual service lines. Multiple palliative medicine product service lines were utilized often, with repeated use of the individual service lines. A comprehensive integrated palliative medicine program is necessary to fully meet the complex needs of those with advanced disease.     

Negotiating the equivocality of palliative care: a grounded theory of team communicative processes in inpatient medicine

In the majority of U.S. hospitals, inpatient medicine teams make palliative care decisions in the absence of a formalized palliative system. Using a grounded theory approach, interviews with inpatient team members were systematically analyzed to uncover how participants conceptualize palliative care and how they regard the communicative structures that underlie its delivery. During analysis, Weick’s model of organizing emerged as a framework that fit the data. The 39 participant inpatient team members discussed palliative care as primarily a communicative process. Themes describing the meaning of palliative care emerged around the concepts of receiver of care, timeline of care, and location of care. The emerging model included four stages in the communicative processes of inpatient palliative care: (a) interpret the need, (b) initiate the conversation, (c) integrate the processes, and (d) identify what works. In contrast to stable, focused palliative care teams or hospice care teams, which have prescribed patient populations and processes, the inpatient medicine team faces the equivocality of providing palliative care within a broader practice. This research offers a four-phase model to show how these inpatient teams communicate within this context. Implications for the provision of palliative care are discussed.     

Hospice utilization during the SARS outbreak in Taiwan

Background  

The severe acute respiratory syndrome (SARS) epidemic threw the world into turmoil during the first half of 2003. Many subsequent papers have addressed its impact on health service utilization, but few have considered palliative (hospice) care. The aim of the present study was to describe changes in hospice inpatient utilization during and after the SARS epidemic in 2003 in Taiwan.     

Developing a physicians' palliative care pain hotline in Maryland

Physicians have had relatively little formal training in pain management and palliative care. For this reason, a telephone consultation service was offered, the physicians' palliative care pain hotline, that would allow physicians to call a toll-free number and, within 15 minutes, speak to a board-certified physician in hospice and palliative medicine. To our knowledge, this is the first program of its kind. This article describes the process involved in creating such a pain hotline and reports on some data collected on its use in the first 10 months. This report should help others who have an interest in establishing a similar program.     

Partners in pediatric palliative care: a program to enhance collaboration between hospital and community palliative care services

The provision of high-quality palliative care services to dying children and their families often requires extensive collaboration between hospital-based and community-based care teams. This article describes the origins and development of the Partners in Pediatric Palliative Care program, which has provided pediatric-specific educational offerings and fostered joint endeavors between a palliative care service located in a tertiary care children's hospital and a wide range of hospice and home care agencies in 5 states. The Partners in Pediatric Palliative Care program is evaluated in terms of the favorable ratings that attendees have given the educational components, the relatively modest direct costs of mounting the regional meetings, and the expanded capacity to provide home-based palliative services to children and families who desire them. The Partners in Pediatric Palliative Care program provides another feasible means for hospitals and community agencies to work together to improve pediatric palliative care.     

Strategies and innovative models for delivering palliative care in nursing homes

The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.     

Program Redesign Based on the Model of Human Occupation: Inpatient Services for People Experiencing Acute Mental Illness in the UK

This paper discusses the current context of the UK mental health service system and the resulting need for program change within acute-care inpatient hospitals. The primary focus is to illustrate through practice example what can be done to support the delivery of client treatment packages by using the concepts described by the Model of Human Occupation (MOHO). The paper concentrates on explaining how MOHO has helped to guide program redesign and develop an Occupational Therapy Care Pathway to support occupation-focused services. The example given is of a hospital service in Gloucestershire, England, which provides inpatient care for people experiencing acute mental illness.     

Palliative care and hospice: one approach

The establishment of the first department of pain medicine and palliative care in a medical center in the United States is a significant marker in the development and impact of the palliative care movement. The integration of Jacob Perlow Hospice into this department is a milestone in the continued evolution of the hospice movement in the United States, and suggests that an interrelationship and interdependence between palliative care and hospice is one of the characteristics of change for the future.     

Antemortem care in an afternoon: a successful four-hour curriculum for third-year medical students

Numerous well-designed studies have shown that patients near the end of life often receive substandard palliative care. Medical students have expressed a strong interest in antemortem care; however, palliative medicine education remains poorly integrated into the overall curriculum at most medical institutions in the United States. In response to this need, a palliative medicine curriculum has been developed for medical students in the required third-year clerkship in family medicine at the University of Tennessee Health Sciences Center The implementation of this curriculum resulted in a statistically significant increase in student competence (as measured by a standardized pretest and post-test) and a significant trend in student confidence (as measured by a single-item Likert scale). The curriculum was popular with students, and encouraged many of them to request hospice clinical experiences during their family medicine clerkship, or to register for the elective fourth-year clerkship in palliative medicine.     

What is palliative medicine? motivations and skills

Palliative care began in the UK hospice movement in the late 1960s and has rapidly developed in many countries since. In some, it has become a fully recognized specialty with comprehensive training programs and recognized expertise in areas such as pain and symptom control. It is important to examine the formative influences and characteristic clinical expertise in palliative medicine. This article considers some of the conceptual, practical, and administrative challenges that have been faced in an effort to establish palliative medicine as a discrete field of specialized practice from a US perspective. We also comment on current issues in regard to education and research, and development of comprehensive palliative care programs in the United States.     

Effectively training the hospice and palliative medicine physician workforce for improved end-of-life health care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.     

The Ohio Hospice Bereavement Study: meeting NHPCO standards

Little attention has been paid to documenting the quality and impact of hospice bereavement programs. While quality of life, quality of dying, and quality of end-of-life measures are common indicators of effective clinical service, they are not adequate gauges of quality from a bereavement perspective. The National Hospice and Palliative Care Organization (NHPCO) published standards for hospice and palliative care programs that included a section on bereavement care. Little evaluative work has been done to discover whether hospice programs nationwide are compliant with these standards. The purpose of this study was to evaluate whether hospice programs (n = 32) in the state of Ohio were meeting the NHPCO bereavement standards. Findings indicated that the participating hospice programs were 83 percent compliant at least some of the time.     

An investigation into the use of palliative care services by patients with prostate cancer

The use of palliative services by prostate cancer patients was assessed in relation to other cancer patients and as a proportion of men diagnosed with prostate cancer. Retrospective analysis ofpalliative care referral and inpatient and outpatient activity was undertaken in respect to patients with nine types of cancer. A cohort of men diagnosed with prostate cancer in 1993 was followed for five years. The records of those that died during this period were reviewed to confirm if they had received hospice care. Of the 118 men dying of prostate cancer, 25.4 percent used hospice services, 23 percent used the hospice at home services (for an average of 68.8 days). while 7 percent used day-care services (for an average of 8.25 days). Prostate cancer patients formed the third largest cancer referral group to hospital-based palliative care services (9.5 percent). They had the third longest survival time from referral (3.8 months) and the oldest average age of death of any group. Lower than average inpatient stays, coupled with the highest average length of stay, led to the third highest use of inpatient services by patients with prostate cancer We concluded that the morbidity from prostate cancer leads to a high use of palliative services. This significant use of resources should be included in comparisons assessing and planning health care strategiesfor prostate cancer     

Providing Palliative Care to Patients Throughout the State of Indiana from a Centralized Virtual Palliative Care Hub

BackgroundAccess to palliative care clinicians is a limited resource. Expanding the reach of existing palliative care expertise by utilizing virtual care is one strategy to reach areas that lack access. We delivered virtual services through a centralized hub across multiple health settings and tracked outcomes.MethodsThrough a centralized virtual palliative care hub based in an urban academic health center, access to specialty palliative care was offered across homes, critical access hospitals (CAHs), and extended care facilities (ECFs) in the state of Indiana. Webpage-based platforms were used, and hardware included a cart on wheels for rural hospital sites. Data specific to palliative care were monitored for each encounter.ResultsOver one year, 372 patients were seen for virtual palliative care consultations, of whom 275 (73.9%) were seen in the outpatient setting (where the patient was at home or in an ECF) and 97 (26.1%) were inpatient visits performed in CAHs. Visits occurred with patients from almost all counties in Indiana. Advance directives were established for 286 (76.9%) patients seen, and 107 (28.8%) patients were referred to hospice.ConclusionSpecialty palliative care is a limited resource that has been further constrained by the COVID-19 pandemic. Our experience demonstrates that centralized virtual hub-based palliative care can be leveraged to provide effective, patient-centered, and compassionate care in regions without a specialist and has the potential to improve access to specialty palliative care.     

Independent hospice care in the community: two case studies

Following its remarkable success over the past 25 years the hospice movement is now at a watershed in its development. The growing legitimacy of palliative care as a health care specialty has coincided with the development of the internal market within public sector services, and the promotion of community care. The impact of these changes is now being felt by the hospice movement and may well result in radically new forms of service provision. The focus of this paper is on the future direction of the hospices. We argue, that in the present policy context the main priority must be palliative care in the community, using two case studies of innovative services to illustrate how this might be achieved. We also explore a variety of factors which may constrain the development of community care for dying people. These include the diminishing experience of families and primary health care workers in managing death and dying and the often strongly held belief that hospice care must be in-patient care. New community services may also face difficulties both in finding a market niche which complements rather than supersedes existing provision, and in securing service contracts where provision cuts across the health and social care divide. These issues are explored through an examination of the models of care developed by the two hospice groups, their integration within existing networks of provision, and their relationship with purchasing authorities.