Richard J. Lin Harvard Medical School August 1, 2003 Chicago, IL

1. American Medical Student Association (AMSA) End of Life (EOL) Education Initiative Project in-a-Box (PIB) Richard J. Lin Harvard Medical School August 1, 2003 Chicago, IL

2. An Experiential Learning Module of EOL Care • Overview of current EOL curriculum • Development of an experiential EOL learning module - The EOL Care Mentorship Program • Program evaluation and assessment • Finance, portability, and future integration into the core curriculum

3. HMS EOL Curriculum Overview

4. Lack of EOL Component in the Current Core Curriculum • MSI and MSII - Popular elective “Living with Life-threatening Illness” • MSIV - Two elective rotations in Pain, Palliative medicine, and Psychosocial Oncology • Residents and Physicians - Elective palliative care rotations and fellowship; faculty development seminar

5. Living With Life-threatening Illness (LWLTI) Course • Developed by two palliative care experts at HMS, Drs. Susan Block (DFCI) and Andrew Billings (MGH) • Course formats are lecture; small group discussion/reflection; case conference; role plays; and individual patient visits • Covers the basics of hospice and palliative medicine: death and dying process; advanced care planning; pain control and symptom management; physician roles; ethical, cultural and spiritual issues

6. Informational and Experiential Gaps in LWLTI • 25 to 30 students enroll each year, accounts for only 7 to 8 percent of the student body • Focus more on integration of palliative care into mainstream medicine and less on utilizing hospice care for dying patients • Most participating patients are in the gray zone with prominent medical issues • Emphasizes physician leadership, no exposure to interdisciplinary team work • PBL cases are not integrated with patho-physiology and clinical medicine

7. The EOL Care Mentorship Program

8. Goals and Objectives • Introduction of the key concepts of hospice and palliative medicine • Experiential learning of EOL care through interdisciplinary team work • Cultivation of student interest in EOL care and palliative medicine • Advocacy of integration of EOL component into the core curriculum

9. The EOL Care Mentorship Program • Forming partnerships with local hospice and hospital-based palliative care teams • Drawing the enthusiasm and expertise of a large number of faculty members who has an interest in EOL care • Targeting mostly first and second year medical students • Assigning two or three students to each hospice/palliative care team; potentially serving as volunteers

10. Potential Partner I : Healthcare Dimensions Hospice • A subsidiary of Dana-Farber Cancer Institute (DFCI) and Partners Healthcare System • Serving all 37 counties in the greater Boston area, currently has 150 patients • Comprehensive hospice service for both adults and children • Non-for-profit, Medicare and Medicaid certified, JACHO accredited • Medical Director and full-time physicians, PCP participation is high

11. Potential Partner II : Pain and Palliative Care Program • Based in DFCI and Brigham and Women’s Hospital (BWH) • Serving mostly cancer patients • Work alongside of the medical team to integrate palliative care into comprehensive plan of care • Interdisciplinary team approach for pain and symptom control and psychosocial support • Physician leadership with Dr. Janet Abrahm (Medical Oncologist)

12. Potential Partner III : Palliative/Supportive Medicine Team • Based in Harvard Vanguard Medical Associate, a community healthcare network • Serving community hospitals, nursing homes, and extended care facilities, predominately serving geriatric population • Consultative services on pain and symptom management and psychosocial support • Physician leadership with Dr. Robert Buxbaum (Internist and Geriatrician)

13. Potential Partner IV : Pediatric Advanced Care Team • Based in Children’s Hospital and DFCI • Serving children with advanced illness • Support medical treatment for underlying illness while provide optimal quality of life • Using a family-centered approach • Extensive grieving and bereavement support for parents • Physician leadership with Dr. Joanne Wolfe (Pediatric Oncologist)

14. Some Possible Activities of the EOL Care Mentorship Program • Home visits with physicians, nurses, social workers, and chaplains • Nursing home visits • Hospital inpatient palliative care rounds • IDG meeting • Clinical case conference • Small group reflection/discussion

15. Logistic Considerations of the EOL Care Mentorship Program • Student time commitment • Faculty time commitment and willingness to teach and supervise • Patient wishes and confidentiality • Logistic arrangement with the hospice and the palliative care team • Longitudinal program vs intensive clinical rotations

16. Program Assessment and Evaluation

17. Participant Evaluation • Pre- and post-test/questionnaire • Preceptor evaluation • Home visit experience write-ups Illness history/treatment/prognosis Pain and symptom management Psychosocial and spiritual distress Patient wishes and family/caregiver concerns Patient-doctor communication and relationship Student learning experience

18. Program Assessment • Participant feedback and suggestion • Faculty/hospice reviews • Patient/family surveys • Assessment by mentors and the curriculum committee

19. Miscellaneous

20. Program Finance • Potential exists for an elective, paid student fellowship program • AMSA seed grant for EOL Education Initiative Project-in-a Box • HMS Community Service Program at the Office of Enrichment Programs • HMS Student Council (student interest group) • HMS Center for Palliative Care • The Neil Samuel Ghiso Foundation (NSGF)

21. The Neil Samuel Ghiso FoundationFor Compassionate Medical Care Mission The Neil Samuel Ghiso Foundation is dedicated to fostering compassionate care for chronically and terminally ill patients and their families through medical education and training. Activities This year NSGF initiated its first program, the Neil Ghiso Fellowship, awarding grants to two Harvard medical students to work with palliative care teams in the treatment of chronically and terminally ill patients. In addition to caring for patients, the fellows will conduct research relating to compassionate care and, at the conclusion of the project, will submit papers reflecting on their experiences and sharing their findings. Over time NSGF plans to expand this program to other medical schools.

22. Program Portability • Stand alone program • Integration into the elective LWLTI course • Integration into the HMS Primary Care Mentorship Program • Expansion and Integration into the Death and Dying Student Interest Group • Integration into the core curriculum (ICM and Patient-Doctor courses) • Adaptable to other medical schools

23. Program Shortcomings • Elective in nature • In program pilot years it may be able to take only 4 to 8 students • Designed mainly for students with advanced knowledge/interest/experience • Lacking an organized didactic component • Time commitment and travel • May not be able to follow the same patient over time due to logistics

24. What I have Learned To Cure Sometimes To Relieve Often To Comfort Always -16th century anonymous

25. Horizon Hospice Dr. Mike Marschke Dr. Mike Preodor Lori Hedges Hospice of Illinois Schuyler Cunningham Jackie Johnson Joanne Murray AMSA Foundation Fellow EOL Interns: Angie, Andy, Ashley, Elizabeth, Erin, Donna, Hamayun, Heather, Jim, Mabel, Melanie, and Munish Thank You So Much !!!