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Building from the Bottom Up: The Palliative Care Program at the Medical College of Wisconsin

Palliative care visionary and medical educator David E. Weissman, MD, reviews the decade of hard work and commitment behind establishment of the Palliative Care Medicine Program at the Medical College of Wisconsin in Milwaukee.
April 2001

David E. Weissman, MD
Palliative Care at the Medical College of Wisconsin
Building from the Bottom Up:

Building from the Bottom Up

Executive Summary

For many years, hospice was the only source of quality, consistent palliative care at the end of life, but the hospice concept was never well integrated into medical education in the United States. Although many U.S. medical schools now include some training in death, dying and palliative care, it is largely restricted to lectures in the preclinical years. Despite the growing number of academic palliative care programs, few medical schools provide consistent training in palliative care in the clinical years, in graduate physician education or in community health professional training programs.

Since 1990, my colleagues at the Medical College of Wisconsin (MCW) and I have been developing progressive layers of a comprehensive Palliative Medicine Program (PMP) that integrates clinical service, undergraduate and graduate medical education and education for healthcare providers in the community. Our mission statement is to improve care for the dying in America through the development, implementation and dissemination of innovative education and clinical care programs.

In its first few years, our program evolved one step at a time in a bottom-up response to perceived needs. We worked largely through the informal network of medical school and hospital staff rather than through the traditional medical school hierarchy of deans and department chairs. While this approach is not the only and perhaps not the most desirable way to effect change in a major medical environment, it is the process that has worked best in our institutional culture.

Despite our continued efforts, however, it became increasingly clear that we were only partially realizing our ultimate goal -- the full integration of palliative care into the culture of the main teaching hospital. Problems encountered on a daily basis included:

  • Lack of end-of-life role models for training physicians;
  • Lack of uniform hospital standards for pain management;
  • End-of-life attitudes among physicians and nurses that impeded good care and defied conventional educational approaches; and
  • Lack of any mechanism for quality improvement of issues important to palliative care such as appropriate analgesic prescribing, routine completion of advance directives by patients at high-risk for death and bereavement support services.

The constant changeover of resident and faculty physicians typical of an academic institution and increasing pressure to enhance clinical income have exacerbated the problem. To address these challenges, beginning in 1997, we added a new dimension to our integrative efforts -- creating institutional change within the primary teaching hospital. The single most important dimension of this effort has been the support of two key members of hospital administration: the physician-in-chief and the director of patient care services. Both were aware of our efforts to improve clinical care and agreed to support our vision of greater integration of palliative care into hospital practice. Only with their support were we eventually able to establish a Palliative Care Committee, reportable to the medical staff, an essential step in "getting us at the table" with other clinical services. Palliative care, an unknown term 10 years ago, is now a readily understood concept within our medical center.

 

Launching the Program

We first proposed a clinical and education palliative medicine program in 1990. Medical, nursing and social services staff from the Medical College of Wisconsin (MCW) Hematology/Oncology Division recognized that care for dying patients was poorly coordinated and that symptom control was given little attention. Our first written proposal presented plans for a clinical program in end-of-life care including dedicated physician, nursing and social worker positions. The program was supported in concept, but financial support was insufficient to proceed.

At the same time, in an unrelated move, the MCW dean of student affairs asked me to develop a course in end-of-life care, an opportunity that would prove to be an excellent entry point for overall program development. An existing undergraduate course, Death and Dying, focused on traditional death education theory, but had little clinical relevance and was poorly received by students. In 1991, we launched Palliative Medicine, a mandatory six-week course (12 contact hours) for second-year medical students that emphasized clinically relevant aspects of care. Course objectives included understanding the:

  • Psychological effects of dying as it relates to the adult or child patient, families, community and health professionals;
  • Physiological aspects of the dying process;
  • Common physical symptoms and their management in dying patients;
  • Concepts of hospice medicine and interdisciplinary care;
  • Basic communication skills necessary to work with dying patients and families in a sensitive and caring manner; and
  • Physician's responsibility in caring for dying patients and their families.

Because its content was clinically relevant, students enjoyed the course, and some indicated an interest in learning more. In 1992, we began a third-year, two-week elective in palliative medicine.

Between 1991 and 1993, we continued to propose a palliative care clinical program. Although hospital administration was enthusiastic about the concept, funding remained unavailable. In 1993, we garnered enough outside support to recruit Julie Griffie, RN, MSN, CS, AOCN, CHPN, to start the Palliative Care Service (PCS), a clinical consultation service for seriously ill and dying patients. PCS clinical activities include:

  • Assisting patients and the medical team with pain and non-pain symptom control;
  • Assisting patients, families and the medical team in end-of-life decision-making; and
  • Serving as a resource for assessment and coordination of end-of-life discharge planning and follow-up.

In designing the PCS, we felt that our greatest area of need, both clinically and educationally, involved patients near the end of life, particularly patients for whom no further life-prolonging therapy was planned. The PCS serves all dying patients, whether the diagnosis is cancer, AIDS, or end-stage heart, lung or neurologic disease. Initially, inpatient and outpatient consultation services were provided by Ms. Griffie and myself, a medical oncologist. Today, the PCS is coordinated by 1.2 FTE physicians and three full-time advance practice nurses. Specialized pain management services are provided by the Department of Anesthesiology Pain Management Center. Supportive psychotherapy and behavioral treatments are provided by one of several staff psychologists with an interest in end-of-life care. The PCS also works closely with representatives from the MCW Bioethics Center. A six-bed inpatient unit with a dedicated chaplain and social worker was added in 1998.

The PCS is now the focal point for all clinical education activities including:

  • Observing trainees conduct patient interviews and symptom assessments;
  • Teaching trainees how to establish a prognosis for appropriate discharge planning;
  • Teaching principles of pain management (including drug and nondrug therapies); and
  • Teaching how bioethical principles are applied to end-of-life decision making.

Consultation Service

New inpatient consultations that are generated by physician referrals are seen within 24 hours. Referrals for assistance from a palliative care nurse without physician involvement are received from nurses, social workers, chaplains, patients and families. Following this type of assessment, a written consultation request from the attending physician is sought if the nurse feels that a palliative care physician assessment is warranted.

In the consultation process, the patient's nurse is interviewed prior to or following the patient interview. Whenever possible, the housestaff or medical student involved with the patient is invited to participate in the patient interview. Depending on the wishes of the referring physician, we may nor may not write orders directly on the chart. When pain or other physical symptoms are the primary issue, we will ask for order-writing privileges to facilitate care. For cases in which decision-making and discharge planning are the central issues, a family conference is organized following the initial assessment. This conference includes the ward team, social services and/or discharge planning personnel and chaplaincy.

With the exception of a dip in 1998, there has been steady growth in consultation requests, which are now more than 450 per year.

Liaison Program

Rather than wait for the typical consultation, an act that first requires the consulting physician to recognize the need for palliative care, we have worked over the past two years to develop a more collaborative model with selected medical services, notably oncology and the medical intensive care unit. On these services, one palliative care nurse has become a part-time member of the medical teams and develops what we believe to be the critical first step in the consultation process, rapport and trust with the referring physician. In the PCS liaison program, a palliative care nurse makes rounds several times per week with these teams. The nurse's role in this liaison relationship is to:

  • Establish working relationships with the attending faculty and residents each month;
  • Assist the physician team and nursing staff to identify palliative care issues;
  • Facilitate and participate in family meetings;
  • Provide direct patient or family palliative care assessments, reportable to the primary team; and
  • Facilitate transfers to the inpatient palliative care ward, home hospice program or other suitable disposition for end-of-life services.

To facilitate timely outpatient consultations, the PCS nurse is available to see same-day outpatient consults, typically in the clinic of origin, during the patient's visit with the referring physician. All patients seen by the PCS nurse as part of the liaison program are discussed with the palliative care attending physician during daily work rounds.

Inpatient Unit

Inpatients on the palliative care unit are cared for under the direction of the primary team, with the PCS as consultants. Care is coordinated in a twice-weekly interdisciplinary team meeting, and all unit staff receive special instruction in end-of-life care. Patients can be admitted directly into the inpatient unit from home or via in-hospital transfer. In-hospital transfers are made with approval of the patient, family, primary physician and nursing staff of the referring unit. For example, it is rare for patients to be moved from the oncology inpatient unit to the palliative care unit. Palliative care services are provided by the PCS on the oncology unit to preserve the typically long-standing patient, family, nurse team relationships. In contrast, all patients coming from the intensive care unit who need end-of-life services are transferred to the palliative care inpatient unit.

Expanding Educational Opportunities

Several principles have guided the development of PMP educational initiatives:

  • Physician education must be longitudinal, starting in the preclinical years and extending throughout housestaff training.
  • Faculty development is essential to promote end-of-life education.
  • Educational efforts must include nurses, pharmacists and other health professionals.
  • Improved communication skills are vital to all aspects of palliative care.
  • Educational activities must include recognition of attitude barriers along with acquisition of both knowledge and skills.

Undergraduate Education

In addition to Palliative Medicine , the required course for second-year medical students, we launched a four-week elective for fourth-year students in 1993. The elective experience includes inpatient and outpatient consultations with the PCS and home visits with hospice staff. In 1995, we merged the Palliative Medicine course with Medical Bioethics, a required first-year course, into a single 10-week, 30-contact hour required course for second-year students called Medical Ethics and Palliative Medicine. (Table 1) Additional palliative care education for medical students occurs during required small group teaching during third-year Internal Medicine clerkship and a fourth-year Preparing for Internship course.

Graduate Education

In an attempt at widening the scope of palliative care education to postgraduate education, we began work with two of our graduate physician education programs, the Internal Medicine Residency and the Waukesha Family Medicine Residency, helping them develop a curriculum and an evaluation program in end-of-life care. We initiated the planning process by conducting a detailed needs assessment to establish a baseline of resident knowledge, comfort and confidence. In 1996, we launched programs that address the deficiencies we discovered and also fit the existing curriculum and evaluation structure of each residency. New curriculum features include a required palliative care lecture series, a competency-based communication skills curriculum, clinical rotations in hospice and palliative care and faculty development.

Faculty Education

Establishing teaching objectives and developing course curricula and teaching materials for end-of-life care will not by themselves change medical practice. Medical school and postgraduate faculty must be trained as both skilled practitioners and educators in end-of-life care. Thus, in 1997, we initiated an eight-week (1.5-hour per week), small group, faculty education initiative, which has become a cornerstone of program development. Course objectives highlight major areas of end-of-life clinical and educational practice:

  • Pain and addictions assessment;
  • Pain management;
  • Assessment and management of nausea/vomiting, delirium and dyspnea;
  • Communication skills;
  • Ethics/law; and
  • Hospice care.

Each session provides complementary learning activities (pretest, didactic presentation, case studies) and time for group discussion and personal reflection about how to use new information to develop a personal action plan. (Table 2) Each case study focuses on learning not only how to provide better end-of-life care but also how to be a better educator. Educational resources and reference material include content outlines, a cancer pain management handbook and pocket reference cards on analgesic management, performance status scales and cognitive assessment. Faculty can use these items for their own learning and immediately apply them to student/resident teaching.

A survey conducted following the first faculty development course found that nine of the 10 faculty who participated in at least three educational sessions provided end-of-life education based on the information they acquired in the course, typically to housestaff, medical students, nurses, patients and other faculty. All used course teaching materials for their own clinical needs, especially pain management, pain/addiction assessment and management of nausea/constipation.

This course is now conducted annually using the same basic format. More than 40 faculty have participated since 1997. Based on our first experience with the faculty course, we learned how difficult it is for faculty to break free from clinical duties to attend class. We have tried to offset this problem by offering the course each year on a different day and at different times.

Nurse Preceptorship Program

In 1993, we began a Nurse Preceptorship Program (NPP) in which nurses from community agencies (hospice, home care, hospital, clinic and long-term care settings) spend three to five days working as members of the PCS. The purpose of this short, intensive, experiential immersion is twofold: to reinforce clinical skills and to prepare nurses to serve as change agents for improved end-of-life care in various clinical settings. The course has been approved for continuing education credit by the Wisconsin Nurses Association.

Key principles of the PMP's approach to community nurse education include:

  • Use of multiple education formats, including lecture, small group and experiential learning opportunities;
  • Incorporation of skills training (eg, pain assessment, care plan development, communication skills);
  • Availability of practical tools (eg, standards, policies); and
  • Ongoing support including availability to respond to questions, provide encouragement and continue the skills development process.

NPP trainees complete a palliative care knowledge survey and personal needs assessment, which is subsequently used as a teaching tool. Faculty review the survey in depth with each trainee, identifying knowledge gaps and attitude barriers and suggesting resources for further education. The program is divided into five modules: pain assessment and management, management of non-pain symptoms, hospice care, professional issues/decision-making and palliative care. Trainees receive a list of learning objectives, learning activities and key references for each module.

Educational opportunities include daily rounds (inpatient and outpatient) with the PCS, attendance at weekly cancer pain rounds, and completion of the teaching syllabus, which contains key articles and case studies. Elective opportunities include attendance at a multidisciplinary pain clinic and HIV or radiation oncology clinics, home visits with a hospice nurse or social worker and attendance at a hospice team meeting.

Experiential learning includes direct patient consultations and written case studies. Trainees are expected to develop plans of care for PCS patients that include management of pain and nonpain symptoms plus identification of relevant psychosocial, ethical and disposition issues. Case studies in the teaching syllabus combine problems of symptom management with decision making and disposition issues to provide a realistic problem-solving challenge. Trainees also work directly with discharge planners to discuss issues related to hospice referral, including finances, identification of home caregivers and level of nursing support needed in the home.

We also help the nurse trainees begin the process of changing the pattern of clinical practice in their own settings. Faculty work with each trainee to identify specific goals of practice change, identify barriers to change and develop a strategy for beginning the change process. Finally, trainees complete a detailed evaluation of the NPP.

To date, more than 250 nurses from community hospitals, home hospice agencies, long-term care facilities, and oncology and HIV clinics throughout the United States have completed the preceptorship experience. Trainees who wanted to become change agents have indicated that they benefited from the role modeling provided by NPP faculty, a key educational tool for assisting practice behavior change.

Community Outreach

We have developed strong ties with community agencies including home and inpatient hospice programs and long-term care facilities, where we place medical and allied health students for short-term educational experiences. In turn, these agencies have participated in education and clinical outreach efforts to improve end-of-life care in their settings. For example, we designed and coordinated two large projects to assist local hospitals and long-term care facilities to develop standards, educational programs and quality measures to improve pain management.

We also have initiated a Palliative Care Observership whereby nonphysician health professionals can work for two to four weeks with the PCS as observers. To date, we have hosted more than 50 professionals including senior nursing students, pharmacy residents, bioethics graduate students and nurses working toward advanced degrees.

Palliative Medicine Seminar

To highlight palliative care as a legitimate aspect of academic medical practice, we began a monthly Palliative Medicine Seminar series in 1993, which is open to all interested MCW and community health professionals. The educational content of these interactive programs is at the level of graduate physicians. The series is now required for Internal Medicine residents. Each seminar averages 50 to 60 participants. The series is the only interdisciplinary conference in the Department of Internal Medicine, attracting physicians, nurses, social workers, discharge planners and clergy. Topics covered in 2000 included pain assessment, discussing prognosis, treatment of end-of-life depression, use of artificial hydration/feeding, conducting a family conference and cross-cultural care.

Creating Institutional Change

True integration of palliative care as a recognized aspect of medical practice, especially within teaching hospitals, will occur when the discipline of palliative care and its practitioners are fully integrated within the culture and administrative organization of hospital practice. This integration includes recognition and utilization by diverse clinical services as well as participation in medical staff and other hospital committees, quality improvement activities, volunteer programming, marketing and hospital fund-raising efforts.

In 1997, with strong support from hospital administration, we began a broader effort to integrate palliative care more fully into routine hospital activities at the main MCW teaching hospital, Froedtert Memorial Lutheran Hospital (FMLH).

Medical Staff Structure/Hospital Committees

In 1998, the hospital established a physician Palliative Care Committee responsible for clinical, educational and quality improvement aspects of end-of-life care that impact the physician staff. The committee includes representatives from the PCS, Cancer Center, Intensive Care Committee, Emergency Department, Ethics Committee, Chaplaincy, Social Services, Organ Donation, Pharmacy and Nursing. The committee is required to make bi-annual oral and written reports to the Medical Management Committee (the physician oversight committee for all clinical activities) detailing committee activities that impact the physician staff. The Palliative Care Committee is now the backbone of virtually all activities in staff education, guideline development and quality improvement. To ensure continued buy-in from physicians, we have emphasized multispecialty physician participation. In 1999, the hospital's Pain Management Committee (see below) was made a subcommittee of the Palliative Care Committee.

Physician representatives from the PCS also have been added to the Cardiopulmonary Resuscitation, Intensive Care and Ethics Committees. In addition, PCS nurses are members of a Quality Improvement Committee charged with oversight of patient rights.

Pain Management Committee

At the request of hospital administration, an ad hoc Pain Management Committee was formed in 1997 by members of the PCS staff to oversee staff education, standards, assessment and quality improvement activities. Committee members include palliative care physician and nursing staff, nursing administration, pharmacy and quality improvement representatives, and physician representatives from general surgery, orthopedics, emergency medicine and anesthesiology. The committee has moved forward on a number of activities including hospital-wide pain management assessment and analgesic standards, patient education material, new pain assessment forms and procedures, a system for ongoing, unit-specific quality assurance monitoring, and a Pain Resource Nurse program (PRN), which includes the identification, training and mentorship of at least one nurse skilled in pain management per nursing unit, per shift.

Bereavement Services

Prior to 1997, FMLH had no formal bereavement program. With administration support, PCS staff organized an ad hoc multidisciplinary Bereavement Committee that completed a detailed needs assessment and developed a hospital-wide Bereavement Program, which debuted in 1998 under direction of the hospital's Chaplaincy Program. The Bereavement Program identifies patients expected to die during hospitalization, provides community resource information and food to families, and provides a checklist of actions to be completed by the patient's nurse, chaplain and social worker prior to, at the time of and following death. Recently, the hospital agreed to recruit a full-time hospital bereavement coordinator.

Guideline Development

Current FMLH policies provide statements outlining physician responsibilities but give little practical guidance in patient management. In 1999, the Palliative Care Committee began development of clinical guidelines for the physician staff. The guidelines were meant to augment existing hospital policies that address key issues in end-of-life care, particularly policies on treatment withdrawal/withholding and do not resuscitate (DNR) orders. The new guidelines offer a literature-based consensus of practical medical, ethical and legal information along with suggestions for how to conduct conversations with patients and surrogate decision makers. For example, the hospital policy Withdrawal or Withholding of Life Sustaining Treatment reviews legal aspects and attending physician responsibilities. The new guideline on use of artificial hydration/feeding at the end of life provides physicians a consensus opinion of medical benefit/burdens and suggested language to use during discussions with patient or surrogate decision makers.

Committee members selected guideline topics based on areas of greatest need. Guidelines were developed by a consensus process among committee members; review and comment by other physician stakeholders in the hospital; and revision and final approval by the Medical Management Committee. To date, three guidelines have been completed:

  • Use of Artificial Hydration and Feeding in End-Stage Dementia and in End-of-Life Care
  • DNR Orders
  • Managing Conflicts in End-of-Life Decision Making

A fourth guideline, Diagnostic Evaluation and Management of Patients Following Prolonged Anoxia, is in development.

Quality Improvement

In addition to the pain management quality improvement efforts noted above, we initiated a more global end-of-life quality improvement effort in 2000. At the request of hospital administration, a hospital-wide assessment was completed under the combined direction of the hospital's Palliative Care and Ethics Committees with support from the Quality Improvement Department. The assessment included:

  • Chart audits;
  • Surveys of key stakeholders (administration, social workers, chaplains, risk management experts, nurse administrators, Ethics Committee staff and Organ Donation staff) (Appendix);
  • Review of hospital end-of-life policies and existing quality improvement measures; and
  • Review of Ethics Committee and PCS consultations from the past year.

In November 2000, a full report was presented to the Medical Management Committee, which in turn authorized the Palliative Care Committee to develop an action plan for moving forward to address the identified problem areas: physician communication skills, physician knowledge of ethics and law, management of advance directives, bereavement support and team approach to care.

The audit of end-of-life care was a major step forward in helping to define the demographics of our dying patients and assess which service areas to emphasize in future quality improvement and education efforts. The fact that these issues have been brought to light and discussed with the hospital physician leadership represents a breakthrough in establishing urgency and creating change.

Fund-raising and Marketing

Academic medical centers are under increasing pressure to find new sources of clinical revenue to support both research and education. Although financial reimbursement is currently available for some portion of our services, in no way does it compensate for the large time expenditures required for the problems encountered. Prior to 1997, the PMP received no hospital financial support. Since then, FMLH has committed significant support to the program including staff salaries, a fund-raising effort for a Palliative Care Endowment Fund, a local marketing effort including brochures, television and print advertising, and local outreach efforts through hospital publications. In addition, the hospital auxiliary has contributed financial support to the program and is assisting in development of a Palliative Care Volunteer Program.

Lessons Learned

The importance of having a clinical palliative care program that interacts directly with patients, families and medical trainees cannot be overemphasized. It is fine to teach palliative care principles to second-year medical students or give a lecture series to housestaff, but without a clinical environment to reinforce these concepts, such teaching is likely to have little or no impact on subsequent practice.

Consistency and Continuity

As physicians in training rotate to different services every month and as each new year brings an entirely new group of physicians, maintaining a consistent level of excellent symptom control is difficult. The PCS helps provide a more consistent level of good pain control along with management of non-pain symptoms.

The PCS also provides a sense of provider continuity to patients who frequently get lost within an academic medical center. As ward teams and attending staff change on a monthly basis, and as patients move between various clinics seeing a multitude of training physicians, it is often difficult for the patient and family to identify one physician who is in charge. As death nears and the issues of life-prolonging versus palliative care and appropriate home-care decisions predominate, the lack of an identified physician who can be a decision maker frequently results in excessive hospitalization and over reliance on aggressive therapies. The PCS serves as a direct link between the patient, family unit, the medical staff and the discharge planners to ensure that appropriate home-care and hospice-care issues are discussed and understood.

Collaboration

The purpose of any consultation is to provide the referring physician with information and guidance in communicating new findings and making patient care recommendations. Thus, the palliative medicine consult is in a special position to help physicians who are struggling not only with patient care problems but often with their personal fears and concerns about end-of-life care. This feature, whereby physicians can have a dialogue with their colleagues about end-of-life care in a traditional and familiar consultation setting, is what distinguishes a palliative medicine consultation from other available patient-centered end-of-life support services.

Future Challenges

Despite our success at integrating end-of-life clinical care and medical education at MCW, some unsolved problems, and their corresponding opportunities, remain. For example, acceptance of palliative medicine clinical services beyond internal medicine and oncology has been slow. Although we have received requests for consultations from every clinical department, the PCS is relatively underused, especially by general and subspecialty surgery services. We hope to continue to expand the PCS Liaison Program to "build bridges" to surgery and other low-referring services.

In addition, only two MCW graduate physician programs currently have a defined end-of-life curriculum, although two more training programs have expressed some interest. We hope to work with other training programs in the coming years to expand palliative care education. If palliative medicine is to become a routine and accepted aspect of academic medicine, there must be greater acceptance of this basic aspect of medical care by educators as well as by senior medical school and hospital administrators.

 

 

SIDEBAR

About the Medical College of Wisconsin

The Medical College of Wisconsin (MCW) is a private, free-standing medical school in Milwaukee. MCW has an undergraduate medical school class of approximately 200 students per year and a graduate training program that includes 72 residency and fellowship programs with more than 700 postgraduate trainees.

Froedtert Memorial Lutheran Hospital (FMLH), a 400-bed tertiary care center, is the main teaching hospital for MCW medical students and residents. The Palliative Medicine Program at FMLH functions administratively within the Division of Hematology/Oncology in the Department of Internal Medicine. Other teaching hospitals include the Zablocki Veterans Administration Medical Center (ZVAMC) and several community hospitals. In 1998, ZVAMC began its own palliative care program, including a consultation and inpatient service, administered within the Geriatric Department.

 

Figure 1

Medical College of Wisconsin Palliative Medicine Program

JPSM 3/98/196

Table 1

Outline for the Second-Year Medical College of Wisconsin Course Medical Ethics and Palliative Medicine

Format: 10 weeks, 3 hours/week; 1.5 hours of didactic lectures followed by a 1.5-hour small group workshop.

Week 1

Professionalism

Basic bioethical principles/ethics committees

Week 2

Informed consent

Decision-making capacity

Week 3

Advance directives

Withholding/withdrawing treatments/futility

Week 4

Confidentiality

Neonatal and pediatric ethics

Week 5

End-of-life care: epidemiology, medical issues

Class interview of a family member of a recently deceased cancer patient

Week 6

Communication issues in end-of-life care: giving bad news, goal setting

Hospice care

Week 7

Psychological issues for the dying child and family

Observed structured clinical encounter, giving bad news

Week 8

Allocation of healthcare resources

Organ transplantation

Managed care and ethics

Week 9

Genetics and ethics

Doctor-patient relationship

Week 10

Abortion

Assisted suicide

Table 2

Examples of Faculty Action Plan Activities

  • Use content outline to teach more rational approach to nausea/vomiting management in the outpatient clinic.
  • Develop flow-chart for constipation management for use with housestaff during inpatient work rounds.
  • Encourage compulsive, old-fashioned history and physicals for all palliative admissions.
  • Role play and set an example for good communication skills with inpatient team.
  • Ask housestaff to do reverse role-playing to understand patient issues in pain and addictions assessment.
  • Use handouts on pain management to teach ward nurses.
  • Share course information with behavioral medicine faculty.
  • Educate colleagues about pain management biases that exist among housestaff and nurses.
  • Develop a lecture on drug therapy/pain management for resident teaching conference.
  • Use communication case studies with ICU housestaff and fellows.

Appendix: Survey of Hospital Stakeholders

I. Please give your impression, based on your personal observations, of the global quality of services for each domain, using the following scale:

1 = poor quality, needs extensive improvement

2 = fair quality, needs major improvement

3 = good quality, needs minor improvement

4 = excellent quality, no changes are needed

9 = I do not have any information to make a judgment

  • Doctor-patient communication (clear, timely, empathic)
  • Attention to the needs of families
  • Cross-cultural sensitivity
  • Bereavement (after-death) care
  • Attention to spiritual and psychological care
  • Adherence to written advance directives
  • Attention to pain and physical symptom management

II. The following is a list of commonly identified problems in care near the end of life. Please rate the degree to which each problem occurs:

1 = occurs very frequently

2 = occurs often

3 = occurs rarely

4 = never occurs

  • Advance directives are not completed in a timely manner in seriously ill patients.
  • There is poor communication between medical team, patient and family about DNR orders.
  • Available support services are not used in a timely manner (e.g. Ethics Committee, Chaplaincy, Palliative Care Service, Patient Relations, Psychology).
  • Aggressive medical interventions in dying patients are over-utilized.
  • Dying patients experience needless physical pain.
  • There is no coordinated program of bereavement services.
  • The cultural needs of patients/families are ignored.
  • The spiritual and psychological needs of patients/families are ignored.
  • There is poor communication between medical team patient and family about clear goals of care.
  • There is poor communication between medical team patient and family about requests for organ donation or autopsy.
  • Patient's written advance directives are ignored.

In your opinion, compared to five years ago, are dying patients receiving better, worse or no difference in their care?

 

References

Weissman DE. Pre-clinical palliative medicine education at the Medical College of Wisconsin. J Cancer Education. 1993; 8:191-195.

Weissman DE, Griffie J. The palliative care consultation service of the Medical College of Wisconsin. J Pain Symptom Manage. 1994; 9:474-479.

Weissman DE. Palliative medicine education at the Medical College of Wisconsin. Wisconsin Medical Journal. 1995;94:505-508.

Griffie J, Weissman DE. Palliative medicine nurse preceptorship at the Medical College of Wisconsin. J Pain Symptom Mange. 1996;12:360-363.

Weissman DE. Cancer pain education for physicians in practice: establishing a new paradigm. J Pain Symptom Mange. 1996;12:364-371.

Weissman DE. Physician education in palliative medicine: a vehicle to change the culture of pain management. commentary. Cancer Pain Release. 1996;9:7-8.

Weissman DE. Consultation in palliative medicine. Arch Intern Med. 1997;157:733-737.

Weissman DE, Griffie J, et al. A role model program to promote institutional changes for management of acute and cancer pain. J Pain Symptom Manage. 1997;14:74-279.

Weissman DE, Norton A, et al. A survey of competencies and concerns in end-of-life care for physician trainees. J Pain Symptom Manage. 1998;15:82-90.

Weissman DE, Griffie J. Integration of palliative medicine at the Medial College of Wisconsin 1990-1996. J Pain Symptom Manage. 1998;15:195-201.

Weissman DE. A faculty development course for end-of-life care. J Palliative Medicine. 1998;1:35-44.

Weissman DE. End-of-life physician education: is change possible? J Palliative Medicine. 1998;2:401-407.

Weissman DE, Block SD, et al. Incorporating palliative care education into the acute care hospital setting. Academic Medicine.1999;74:871-877.

Weissman DE. Cancer pain as a model for the training of physicians in palliative care in Topics in Palliative Care, Portenoy RK, Bruera E, eds. Oxford University Press, 2000:4119-130.

Weissman DE, Griffie J, et al. Building an institutional commitment to pain management in long-term care facilities. J Pain Symptom Manage. 2000;20:35-43.

Weissman DE, Griffie J, Muchka S. Development and services of a hospital- based palliative care program in Oncology Issues (Suppl) Symptom Management for the Cancer Patient, 2000.

 


Additional Resources

The Balm of Gilead Project
A CAPC Fall Forum 2000 Workshop
PowerPoint Presentation

Pioneer Programs in Palliative Care: Nine Case Studies
Milbank Memorial Fund

Palliative Care in Lexington, KY: Three Hospitals and a Hospice
PowerPoint Presentation

Current Medicare Financing for EOL and Palliative Care
Center to Advance Palliative Care Issue Brief



Other Resources By

David E. Weissman, MD


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