Christian Davis Furman

Do Palliative Consultations Improve Patient Outcomes

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care.

A Nationwide VA Palliative Care Quality Measure: The Family Assessment of Treatment at the End of Life

OBJECTIVES To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN Nationwide telephone survey. SETTING Five VA medical centers. PARTICIPANTS Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patients death (3 items). RESULTS Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Unlocking the Closed Door: Arguments for Open Access Hospice

The traditional view of standard hospice (SH) care is that once begun, the doorway toward curative and other forms of nonpalliative treatment is irrevocably locked. We will argue that such a traditional view needs to be reassessed in light of new arguments and data regarding access to these avenues of treatment. We will argue that patients should be supported in their transition from SH to open access hospice (OAH). Open access hospice should be available to all patients because of ethical arguments, patient satisfaction arguments, and costs of care arguments. More randomized controlled research trials need to be performed to study the impact of OAH versus SH. This research should focus on patient satisfaction, cost, and survival.

Eliciting goals of care in a nursing home.

OBJECTIVES To identify enablers and barriers facing providers and staff in initiating Goals of Care (GOC) discussions with patients in the nursing home. DESIGN Qualitative methods, one-on-one interviews. The interviews began with eliciting the participants definition of GOC. The open-ended questions were designed to assess recent experience and satisfaction with the participants role in the GOC discussion. SETTING Nursing home. PARTICIPANTS We interviewed 23 nursing home staff and providers. MEASUREMENTS Transcripts were qualitatively analyzed. RESULTS Five themes emerged that were identified as barriers to discussing GOC: (1) Fear of legal ramifications; (2) Not enough education on how to have a GOC discussion; (3) Family not involved on a regular basis; (4) Time pressure; (5) Interdisciplinary team not involved. Five themes also emerged that were identified as enablers to the GOC discussion: (1) Education/experience with the GOC discussion; (2) Interdisciplinary team involved in the discussion; (3) Established trusting relationship with the patient/family/other staff; (4) Terminal diagnosis/hospice involvement; (5) Discussion occurs in-person. CONCLUSION A major finding of these interviews is the lack of systematic attention to GOC in the nursing home setting. Since education and experience were identified as crucial to understanding GOC, more formal education and observed practice discussing GOC is needed for all staff. The outcomes of GOC discussions should be documented in the patient record and be accessible to all staff and communicated systematically to all staff. Addressing these barriers and facilitating these enablers to the GOC discussion will improve the care of nursing home patients.

Meeting American Council of Graduate Medical Education Guidelines for a Palliative Medicine Fellowship through Diverse Community Partnerships

BACKGROUND The field of hospice and palliative medicine has grown to include more than 50 fellowship training programs. In 2007 hospice and palliative medicine received American Board of Medical Specialties (ABMS) recognition as a subspecialty of medicine. Palliative medicine fellowships will begin formal accreditation under the American Council of Graduate Medical Education (ACGME) in 2008. OBJECTIVE This paper details how one academic institution complied with draft ACGME Program Requirements for Fellowship Education in Hospice and Palliative Medicine addressing training sites and experiences by utilizing innovative community partnerships. RESULTS Through carefully designed collaborative partnerships with community organizations three draft ACGME requirements for accreditation were met. It is anticipated that the program will receive full accreditation through the ACGME in 2008.

Nutrition and End-of-Life Care

Nutritional support during the last days of a dying patient is a critical issue that must be resolved by careful discussion between families, caregivers, and the health care team. Eating is such an integral part of life that when a loved one no longer wants to eat or cannot eat, some families and physicians feel they must do something to correct the situation. Food nourishes us, satisfies us when we are hungry, and comforts us in times of need. We celebrate everything with food and talk of food as “nourishing people back to health.” We prepare and share meals as a way of expressing love and concern. In many instances, however, there is a natural decline in the desire and ability to eat by a family member with a terminal illness, which may be hard for caregivers to understand or accept. Health care providers need to be well-versed in issues regarding artificial nutrition and hydration in terminal illness in order to assist patients and their families in treatment decisions.

Diagnostic challenges in Creutzfeldt-Jakob disease: case report.

Sporadic Creutzfeldt-Jakob disease (CJD) is the most common prion disease. The diagnosis can be confirmed only by histological examination of brain tissue obtained at biopsy or at autopsy. Because of the transmissible nature of the disease, autopsy or brain biopsy cannot be performed at many institutions, which poses numerous challenges in confirming the diagnosis. We report the case of a patient with CJD in which autopsy to confirm the diagnosis was performed after overcoming numerous obstacles and advocating with hospital leadership. This case illustrates the numerous challenges that exist in achieving a definitive diagnosis of CJD and in postmortem disposition of the body, and we provide recommendations to clinicians who face similar challenges.

Human Flourishing and Integrated Care Models: The Development of the Flourish Index

Background and Objectives In evaluating integrated care models, traditional quality measures do not account for functional and quality of life factors, affecting older adults with multiple chronic conditions. The objective of this study was the development and validation of the Flourish Index (FI), an instrument to evaluate integrated care, using a determinants of health model. Research Design and Methods The study took place within the evaluation study of the Flourish Model (FM). The FM provides care coordination services using an integrated primary care and community-based services model. Baseline data from 70 older adults were used in the validation study. Twenty-seven quality of care indicators within six determinants of health, namely biological, psychological, individual health behaviors, health services, environmental, and social, formed part of the FI. Results Categorical principal components analysis showed a 5-dimensional structure with psychological determinants loading on the biological determinants of health. Internal consistency (Cronbachs alpha) for the determinants was as follows: biological/psychological = 0.73, individual = 0.58, environmental = 0.62, health services = 0.65, social = 0.67, total score = 0.97. Sensitivity to change was shown for the total FI score (F1,22 = 8.82, p = .01) and social (F1,22 = 5.82, p = .02), with a trend toward sensitivity for individual health behaviors (F1,22 = 3.95, p = .06) and health services (F1,22 = 3.26, p = .09). Discussion and Implications The preliminary analysis of the FI shows promise for the usability of the index to provide insight into the fundamental challenges of aging. It brings greater clarity in caring for older adults and supports quality evaluation of integrated care coordination models.

Implementing Chief Resident Immersion Training (CRIT) in the Care of Older Adults: Overcoming Barriers and Promoting Facilitators

The Chief Resident Immersion Training (CRIT) in the Care of Older Adults curriculum was developed at Boston University School of Medicine to improve the care of older adults through an educational intervention. The curriculum targeted chief residents (CRs) because their role as mediators between learners and faculty provides the greatest potential impact for transmitting knowledge. The goals of CRIT are to: (1) provide education on geriatric principles and on teaching/leadership skills, (2) foster interdisciplinary collaboration, and (3) complete an action project. This study demonstrates successful implementation of CRIT at a different academic institution in a rural state. The CRs indicated that their confidence in their ability to apply and teach geriatrics improved after CRIT. In addition, the CRs indicated that CRIT improved their confidence in their overall skills as CRs. The barriers and facilitators to implementation are addressed in order to promote successful adoption of CRIT at other institutions, including those in rural states.

Overcoming barriers to interprofessional education in gerontology: the Interprofessional Curriculum for the Care of Older Adults

A fragmented workforce consisting of multiple disciplines with varying levels of training and limited ability to work as a team often provides care to older adults. Interprofessional education (IPE) is essential for preparing practitioners for the effective teamwork required for community-based, holistic, person-centered care of the older adults. Despite numerous programs and offerings to advance education and interdisciplinary patient care, there is an unmet need for geriatric IPE, especially as it relates to community-dwelling older adults and caregivers in medically underserved areas. A core group of university faculty from multiple disciplines received funding from the Health Resources and Services Administration Geriatric Workforce Enhancement Program to collaborate with community-based providers from several Area Agencies on Aging in the creation and implementation of the Interprofessional Curriculum for the Care of Older Adults (iCCOA). This geriatric curriculum is interprofessional, comprehensive, and community-based. Learners include third-year nursing students, nurse practitioner students, third-year medical students, internal medicine and family medicine residents, master’s level social work students, third-year pharmacy students, pharmacy residents, third-year dental students, dental hygiene students, community-based organization professionals, practicing community organizers, and community health navigators. This article describes the efforts, successes, and challenges experienced with this endeavor, including securing funding, ensuring equal representation of the disciplines, adding new components to already crowded curricula, building curriculum on best practices, improving faculty expertise in IPE, managing logistics, and ensuring comprehensive evaluation. The results summarize the iCCOA components, as well as the interprofessional domains, knowledge, and competencies.