Improving generalist palliative care for hospitalized seriously ill patients

IMPROVING GENERALIST PALLIATIVE CARE-A 40 page guidebook focusing on the education and systems changes necessary to embed Goal of Care Conversations into routine care for seriously ill hospitalized patients. The book contains a step-by-step guide of key process steps along with a sample EMR template, quality improvement guides, clinician communication guide, clinician education resources and more. This work is based on the experiences at Aurora West Allis Medical Center, Milwaukee Wisconsin with consultative help from David E. Weissman, MD. Authors are: David E. Weissman, MD, Tim Jessick, DO, Andrew McDonagh, MD and Suzie Feuling, RN, MS, CPH

Discussing what matters most: designing a medical student curriculum for end of life care

Discussing what matters most: designing a medical student curriculum for end-of-life care Natanya S. Russek, Karrie Lu, Kjersti Knox, Timothy Jessick Background: As the population ages, patients are living longer with complex illnesses. While physicians of all specialties are expected to provide patient-centered end-of-life care, studies demonstrate that medical students lack comfort discussing these topics with patients. Our aims were to identify gaps in medical student education and to design and implement a hands-on, longitudinal curriculum to teach essential skills for providing compassionate and skillful care to patients nearing the end of life. Methods: We followed the six-step approach for medical curriculum development: problem identification, needs assessment, goal-setting, identifying educational strategies, implementation, and evaluation development. We reviewed national and local curricula and surveyed graduating medical students. Goals, objectives, and curriculum design were developed with input from student and faculty interviews. Qualitative and quantitative evaluation is ongoing. Results: Literature review revealed that students are exposed to goals of care, breaking bad news, and code status discussions. However, students lack opportunities to practice and receive feedback on these skills. Ten students training as a cohort in a longitudinal clinical and urban medicine program were surveyed in a needs assessment prior to graduation; all reported exposure to goals of care conversations and 10% reported confidence. Similarly, 100% reported exposure to breaking bad news but only 20% reported confidence. The curriculum includes multiple hands-on teaching sessions where students practice breaking bad news and goals of care conversations. Peers and physician facilitators observe and provide active feedback during mock patient interviews. The initial iteration of the curriculum has been received with positive feedback. Conclusions: Implementing a longitudinal curriculum in palliative and end-of-life care is necessary and feasible to improve education of future physicians. Students are expressing increased confidence after a few sessions, and training is ongoing. Future curriculum evaluation will include comparison of experience and confidence in key clinical skills before and after exposure to this novel curriculum. Integrating hands-on practice in these critical skills into medical student curricula will impact the quality of care provided by trainees as they pursue careers in diverse specialties

The impact of goals of care conversation training

Background: Palliative interventions by nonpalliative health care providers such as hospitalists have proved to be beneficial to patients. A primary task of these providers is to hold goals of care (GOC) conversations with patients early during their hospital stay. This can help reserve the expertise of palliative care specialists for more complex patients. While a previous local evaluation focused on providers’ overall comfort in initiating GOC conversation before and after an intervention, no study has explored whether the intervention resulted in providers having more GOC conversations. Purpose: To explore whether GOC training sessions increased hospitalists’ utilization of the GOC dotphrase generated by the Epic electronic health record; also, to evaluate if there was an improvement in the overall quality of GOC conversations held with patients upon admission. Methods: Aurora Health Care hospitalists participated in training sessions covering GOC conversations during 2017–2018. We reviewed 200 history and physical notes (H&Ps) for 5 full-time hospitalists before and after training. H&Ps were reviewed only for patients who were ≥65 years of age and admitted directly to the intensive care unit. For each hospitalist, only the 20 most recent charts before and after the intervention were included. Documented GOC conversations were tabulated, including the use of the GOC dotphrase. Quality assessment was done by searching for goalconcordant keywords and their synonyms within these conversations. Basic descriptive statistics were used to describe the population. Chisquared tests and t-tests were used as appropriate to compare groups. Results:Patient demographics of H&Ps reviewed were as follows: 95% White, 59% female, and mean age 79 years. Older patients (mean: 84 years) were more likely to have a GOC conversation (P Conclusion: Half-day training sessions in conducting goals of care conversations were associated with an increased usage of the GOC dotphrase. Our next steps will be to broaden the scope of this study by not only retraining hospitalists but also including providers from other facilities in our analysis, thus increasing the number of analyzed patient history and physical notes

Goals of care conversations: an evaluation

Background: Growing evidence suggests that physician and patient discussions about goals of care improve quality of life, quality of dying, and decrease end-of-life intensity of care. However, these conversations do not occur at the frequency desired by seriously ill and dying patients. Practitioners recommend new approaches to increase the frequency and quality of such conversations. The “Teaching Primary Palliative Care” training offered through Aurora Health Care’s continuing professional development office is one new approach aimed to equip physicians with skills to increase the frequency and quality of goals of care conversations. Purpose: To evaluate the Teaching Primary Palliative Care (TPPC) training to determine if physicians report increased comfort in engaging in goals of care conversations with seriously ill and dying patients posttraining. Methods: TPPC training occurs in three stages. Stage A: Initial self-assessment completed online. Participants complete a survey in which they answer a series of questions designed to measure comfort level in engaging in goals of care communications with their seriously ill and dying patients. Stage B: Attend an in-person training session on communication skills and techniques on having goals of care conversations with patients. Stage C: Second self-assessment completed online within about 3 months after physicians practiced and applied skills in their clinical practice. In fall 2018, 78 Aurora physicians completed stages A and B of the training, resulting in 37 completed stage A and stage C selfassessments. To assess for increased comfort level, the stage A and stage C assessments were statistically analyzed using the 1-sided sign test. Results: Compared to their reported comfort level prior to completing TPPC training, physicians’ comfort level after training increased in 4 out of 5 circumstances related to engaging in goals of care conversations with patients: discussing CPR/do not resuscitate (P=0.018); discussing hospice or palliative care referral (P\u3c0.001); discussing artificial hydration or nutrition (P=0.001); and discussing prognosis specifics (P=0.002). Conclusion: Findings suggest that TPPC training increases the comfort level of physicians to engage in goals of care conversations with seriously ill and dying patients. Next steps for this project include a longitudinal study to determine whether physicians continue to be more comfortable in these circumstances 6–9 months after completing the training

Goals of care conversations: A training program evaluation

Background: Patients benefit when their health care providers engage in conversations about treatment options and goals of care. However, these conversations frequently do not occur. Researchers have called for new approaches to increase such conversations. The Teaching Primary Palliative Care Training program is one such approach. Purpose: To determine whether Teaching Primary Palliative Care Training increases participant comfort engaging in goals of care conversations with seriously ill and dying patients shortly after the training and 1 year after the training. Methods: 78 health care providers participated in Teaching Primary Palliative Care Training during the fall of 2018. Participants completed a self-assessment in which they reported on their comfort level in various circumstances related to the management of seriously ill and dying patients at baseline before the training, shortly after completing the training, and again 1 year later. We used the 1-sided sign test to assess for statistically significant improvement in self-reported comfort. Results:At the first follow-up, self-assessments reflected significant improvement in comfort, compared to baseline, in all 5 circumstances related to the management of seriously ill and dying patients. These circumstances included: delivering bad news (P=004); discussing CPR/DNR (P=003); discussing hospice or palliative care referral (P=001); discussing artificial hydration or nutrition (eg, percutaneous endoscopic gastrostomy tubes) (P Conclusion: In this sample, participation in the Teaching Primary Palliative Care Training program increased health care provider comfort in patient communication of various circumstances related to the management of seriously ill and dying patients. Improvements continued 1 year after the training. Next steps include determining whether increased comfort translates into changes in provider behavior such as conducting goals of care conversations with patients