1-week required rotation in Palliative (EOL) care

1. 1-week required rotation inPalliative (EOL) care Frank A. Filipetto, DO and Lucia Beck Weiss, MS UMDNJ – SOM (Family Medicine) Janet M. Lieto, DO Samaritan Hospice

2. 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.

3. Why an EOL Competency? • Physicians: • Are poor prognosticators 1 • Delay institution 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

4. Background • Funded by HRSA (AAU) grant • One week required rotation within Family Medicine clerkship year IV • Follows or precedes a one week CPM rotation • Variety of learning methodologies • Cultural and Interdisciplinary competencies • Community resources (Hospice, funeral homes)

5. 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.

6. 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

7. Faculty and Components 1 Week Palliative Care Rotation • Web-CT • Samaritan Hospice • House and Funeral home visits • Standardized Patient Encounters

8. Schedule for Palliative Week • Monday 8:00 AM Orientation and/or Pre-test Make Phone Calls to arrangement Funeral Home Visits Afternoon – WebCT (must be reviewed for Tuesday) • Tuesday 9:00 AM Tuesday PM Samaritan 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 assignment Web-CT, Readings and Assignments • Thursday 8:30 am Home Visits with Dr. Herring (or alternative arrangements) PM Funeral Home Visits; Web-CT; Complete “Attitudes and Concepts of Death and Dying” Worksheet • Friday 1:15 PM - Standardized Patient Cases

9. On-Line Course

10. Web-CT • Development of online course • Looked at existing resources • EPERC – 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

11. Overview-Dying-in-America   Hospice Breaking-Bad-News Family-Conference Culture-and-End-of-Life-Care Treatment-Goals DNR Artificial-Nutrition Depression Constipation Dyspnea- and Delirium Nausea-and-Vomiting Pain-Assessment Pain-Drug-Therapy Pain-or-Addiction Modules

12. Let’s Visit the Website www.umdnj.edu/webct

13. Tracking Tools

14. Instructor Tools

16. 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 items • Student must score above 70% to pass rotation } 23% increase

17. 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.

18. Student Feedback – n=92 • 78 student 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.

19. Student Comments • It'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.

20. Funeral Home Assignment

21. 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 exhaused. He has been referred back 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.

22. Partnering with Samaritan Hospice

23. 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

24. Partnering with Samaritan HospiceWhat makes it work • Samaritan Center for Grief Support • Specialized programs • Tender Hearts • Jewish Hospice • Catholic Ministry • Veterans Outreach • Wound Care Team • Pediatric Palliative Care • Transitions (PreHospice Program)

25. Partnering with Samaritan HospiceWhat makes it work • Institute for Education and Research • Values Evidence Based Medicine • >300 professional and community education program/year • Patient Reported Outcomes Measures (PROM) in partnership with Hospice Pharmacia • Passionate staff who love to teach

26. Partnering with Samaritan HospiceStudents Experience • Interdisciplinary Team Meeting • Physician • Nurses (RN, LPN) • Social worker • Chaplain • Bereavement • Complementary therapies

27. Partnering with Samaritan HospiceStudents Experience • Debriefing Students After Team • History of hospice • Hospice regulations • Hospice criteria • Certification • Physician’s responsibilities’ • Hospice and subspecialties (THIS MEANS YOU!!!) • Answer all questions

28. Partnering with Samaritan HospiceStudents Experience: Inpatient Unit • Interdisciplinary Team Rounds • Hands on patient evaluations • Spiritual and emotional factors • Family concerns • Psychosocial factors

29. Pain-Pain-Pain Dyspnea Nausea and vomiting Constipation Delirium Hiccups Cachexia Seizures Anxiety Depression Muscle spasms Insomnia Agitation Pain-Pain-Pain Samaritan Inpatient UnitAggressive Symptom Management

30. Samaritan Inpatient UnitActively Dying Patients • Signs and symptoms • Management of patient • Terminal agitation • Dealing with families • Palliative sedation • Caring for staff

31. Questions Thank you!