Kristen Schaefer

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

Purpose Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. Method Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. Results The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. Conclusions This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

Physician communication with families in the ICU: evidence-based strategies for improvement.

Purpose of reviewSkilled physician–family communication in the ICU has been shown to improve patient outcomes, but until now little attention has been given to the effect of communication on family satisfaction and bereavement outcomes. The aim of this review is to outline the recent evidence that effective physician communication with families, and proactive palliative care interventions, can improve outcomes for both patients and family members in the ICU. Recent findingsNew data from the ICU correlates physician ability to identify and respond to emotion and to effectively share prognostic information with improved outcomes. Furthermore, proactive palliative care interventions that promote family meetings, use of empathic communication skills, and targeted palliative care consultations can improve family satisfaction, reduce length of stay in the ICU and reduce adverse family bereavement outcomes. SummaryEmpathic communication, skilful discussion of prognosis, and effective shared decision-making are core elements of quality care in the ICU, represent basic competencies for the ICU physician, and should be emphasized in future educational and clinical interventions.

Enrollment and events of hospice patients with heart failure vs. cancer.

CONTEXT Hospice care is traditionally used for patients with advanced cancer, but it is increasingly considered for patients with end-stage heart failure. OBJECTIVES We compared enrollment patterns and clinical events of hospice patients with end-stage heart failure with those of patients with advanced cancer. METHODS Using Medicare data linked with pharmacy and cancer registry data, we identified patients who were diagnosed with either heart failure or advanced cancer between 1997 and 2004, admitted to hospice at least once after their diagnosis, and died during the study period. We compared patterns of referral, use of acute services, and site of death of hospice patients with heart failure with those of patients with advanced cancer. Logistic regression models were constructed to determine the factors associated with late hospice enrollment as well as the use of and death in acute care. RESULTS We identified 1580 heart failure patients and 3840 advanced cancer patients: mean ages were 86 and 80 years, 82% and 68% were women, and 97% and 94% were white, respectively. Compared with patients with advanced cancer, those with heart failure were more frequently referred to hospice from hospitals (35% vs. 24%) and nursing facilities (9% vs. 7%) (both P<0.01). Discharge from hospice before death was similar for patients with heart failure and patients with advanced cancer (10% vs. 9%, P=0.03). Among patients remaining in hospice, patients with heart failure were more likely to have been enrolled within three days of death (20% vs.11%, P<0.01). The prevalence of death in acute care settings was low in both groups after hospice enrollment (4% heart failure vs. 2% advanced cancer, P<0.01). Although the median interval between enrollment and death was shorter for heart failure patients (12 vs. 20 days, P<0.001), emergency department visits and hospitalizations after hospice enrollment were more frequent in patients with heart failure (13% vs. 10% and 9% vs. 6%, respectively, both P<0.01). CONCLUSION Compared with patients with advanced cancer, referral to hospice is more often initiated during acute care encounters for patients with end-stage heart failure, who also more frequently return to acute care settings even after hospice enrollment.

Integrating palliative care into routine care of patients with heart failure: models for clinical collaboration

Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.

Social Worker–Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial

Importance Palliative care considerations are typically introduced late in the disease trajectory of patients with advanced heart failure (HF), and access to specialty-level palliative care may be limited. Objective To determine if early initiation of goals of care conversations by a palliative care–trained social worker would improve prognostic understanding, elicit advanced care preferences, and influence care plans for high-risk patients discharged after HF hospitalization. Design, Setting, and Participants This prospective, randomized clinical trial of a social worker–led palliative care intervention vs usual care analyzed patients recently hospitalized for management of acute HF who had risk factors for poor prognosis. Analyses were conducted by intention to treat. Interventions Key components of the social worker–led intervention included a structured evaluation of prognostic understanding, end-of-life preferences, symptom burden, and quality of life with routine review by a palliative care physician; communication of this information to treating clinicians; and longitudinal follow-up in the ambulatory setting. Main Outcomes and Measures Percentage of patients with physician-level documentation of advanced care preferences and the degree of alignment between patient and cardiologist expectations of prognosis at 6 months. Results The study population (N = 50) had a mean (SD) age of 72 (11) years and had a mean (SD) left ventricular ejection fraction of 0.33 (13). Of 50 patients, 41 (82%) had been hospitalized more than once for HF management within 12 months of enrollment. At enrollment, treating physicians anticipated death within a year for 32 patients (64%), but 42 patients (84%) predicted their life expectancy to be longer than 5 years. At 6 months, more patients in the intervention group than in the control group had physician-level documentation of advanced care preferences in the electronic health record (17 [65%] vs 8 [33%]; &khgr;2 = 5.1; P = .02). Surviving patients allocated to intervention were also more likely to revise their baseline prognostic assessment in a direction consistent with the physician’s assessment (15 [94%] vs 4 [26%]; &khgr;2 = 14.7; P < .001). Among the 31 survivors at 6 months, there was no measured difference between groups in depression, anxiety, or quality-of-life scores. Conclusions and Relevance Patients at high risk for mortality from HF frequently overestimate their life expectancy. Without an adverse impact on quality of life, prognostic understanding and patient-physician communication regarding goals of care may be enhanced by a focused, social worker–led palliative care intervention that begins in the hospital and continues in the outpatient setting. Trial Registration clinicaltrials.gov Identifier: NCT02805712.

Prognosis, Communication, and Advance Care Planning in Heart Failure: A Module for Students, Residents, Fellows, and Practicing Clinicians

Introduction The increasing prevalence, high symptom burden, and medical advances that often prolong the advanced phase of heart failure mandate an organized and thoughtful approach to medical decision making. However, many clinicians have difficulty discussing prognosis and goals of care with patients. Barriers include disease- and therapy-specific prognostication challenges in heart failure and a lack of evidence-based primary palliative care education initiatives. Methods In response, we developed this 45-minute training module, which consists of a case-based small-group session and a communication guide. The curriculum highlights prognostication challenges in heart failure and introduces an illness trajectory-based framework to cue iterative goals of care conversations. Results We piloted this learning module with 46 internal medicine residents and interdisciplinary palliative care fellows in groups of three to 15 and obtained anonymous quantitative and qualitative postsession learner survey data to examine feasibility and acceptability. Trainees rated the session highly. One hundred percent of learners either strongly agreed or agreed the session was clinically useful. Learners unanimously found the teaching methods effective, and most felt they could easily apply these skills to their clinical work. In open-ended feedback, learners said the session gave them a better understanding of the heart failure illness trajectory, an improved framework for discussing goals of care with heart failure patients, and specific language to use when having these discussions. Discussion This module represents a new paradigm for teaching both prognostication and advance care planning in heart failure in which illness trajectory guides timing and content of goals of care conversations.

Palliative Care Education in Cardiology

Advanced heart disease (AHD) represents a significant health burden worldwide. Due to an aging population and improved treatments for AHD, cardiologists will increasingly care for patients toward the end of life (EOL). Despite growing evidence that the integration of palliative care (PC) for

Primary Care for the Elderly Bereaved: Recommendations for Medical Education

The aim of this study was to explore the current practices of primary care physicians (PCPs) in providing bereavement care to elderly patients, with implications for medical education. A total of 63 PCPs answered a brief online survey about their typical practices, barriers, comfort level with bereavement, and confidence in their ability to diagnose prolonged grief disorder (PGD). They were recruited through an online newsletter and contacts of one of the authors. The results found that two-thirds of the PCPs do not routinely screen their elderly patients for recent losses, nor do they refer to mental health clinicians when loss is identified. Barriers included not learning of the deaths in patients’ lives and lack of time during clinic visits. Those PCPs who had experienced their own losses were significantly more comfortable in speaking to patients about recent losses and more confident in their ability to diagnose PGD. We recommend bereavement education be incorporated into the medical school curriculum from the outset, utilizing the psychological principle of graded exposure to bereaved individuals.

From Renin-Angiotensin to Hospice Referral: A Multidisciplinary Approach to Heart Failure (P16)

person care in a team setting. We are a passionate people, bringing empathy and healing when a cure is no longer the goal of treatment. The culture and omnipresent financial constrictions of our healthcare system often make it hard to provide care at the standard we dream of. The teams are often cut down to one nurse or doctor working in isolation, feeling lonely, and overwhelmed by the task. Call schedules are tiring. The administrative burdens often weigh down our efforts. All of this can lead to what has been described in many terms: compassion fatigue, burn out, or, simply, exhaustion. This workshop was created by a group of palliative care providers from many different backgrounds including chaplaincy, social work, counseling, pharmacy, medicine, and psychiatry. Over the course of the past year, we have come together once a month to create a safe, sacred space for ourselves that allows us to reconnect with each other and with what draws us into this field and continues to make it meaningful. We have painted, listened, written, reflected, and created this workshop as part of our process. Come and experience for yourself how invigorating it can be to share this experience with your peers. Explore a variety of creative and reflective activities in a safe setting. Decide for yourself which of these tools might be helpful to incorporate in your own professional environment, so that when you return home, it will be with renewed enthusiasm and an excitement to share with those around you.