Mark Pfeifer

The discussion of end-of-life medical care by primary care patients and physicians

AbstractObjectives: To identify primary care patients’ and physicians’ beliefs, attitudes, preferences, and expectations regarding discussions of end-of-life medical care, and to identify factors limiting the quality and frequency of these discussions. Design: Descriptive study using audiotaped, structured, qualitative interviews. Setting: Ambulatory care clinics and offices at eight medical centers in six states. Participants: Forty-three primary care physicians and 47 ambulatory outpatients. Results: The patients expressed strong feelings about having end-of-life discussions early in their medical courses while they were competent. They desired straightforward and honest discussions and were less concerned than the physicians about damaging hope. The patients wanted their physicians to play central roles in discussions and both the patients and the physicians noted the impact of the patient-physician relationship on these discussions. The patients desired information focusing more on expected outcomes than on medical processes. The physicians expressed feelings of ambiguity when their desire to save lives clashed with their belief that aggressive life-sustaining treatments were futile. The physicians described their roles in end-of-life discussions in five major categories: lifesaver, neutral scientist, guide, counselor, and intimate confidant. The physicians considered living wills excellent “icebreakers” for starting discussions but of limited utility otherwise. Conclusions: Patients prefer end-of-life discussions earlier and with greater honesty than physicians may perceive. These discussions are inseparably linked with the patient-physician relationship. Physicians can better address patients’ desires in end-of-life discussions by altering their timing, content, and delivery.

Senior Medical Students' Perceptions of the Adequacy of Education on End-of-Life Issues

CONTEXT It is unclear how well prepared U.S. senior medical students are to handle end-of-life issues as they reach the end of medical school. Additionally, the most optimal way of providing medical student end-of-life education has not been adequately defined. OBJECTIVE This study aims to determine the preparedness of senior medical students at U.S. medical schools regarding end-of-life issues. DESIGN A self-administered survey. SETTING Six medical schools throughout the United States, two of which have a formal curriculum on end-of-life issues, and four of which do not. PARTICIPANTS Fourth-year medical students during November through February of their senior year. MAIN OUTCOME MEASURE Self-reported preparation on a number of end-of-life competencies. RESULTS Of the 757 surveys sent out, 262 responses were received (34.6%). Only 22% to 53% of students (varying by topic) felt prepared by their education in the selected end-of-life competencies. Students attending medical schools with a formal end-of-life curriculum were more likely to feel prepared than students with no formal curriculum to address psychosocial issues (21% higher, p = 0.008), cultural/spiritual issues (21% higher, p = 0.005), technical aspects of end-of-life care (18% higher, p = 0.001), and treatment of common symptoms (34% higher, p = 0.001). Students who had more clinical experiences in palliative care were more likely to feel prepared to discuss end-of-life issues with patients (p = 0.013) and to treat common symptoms (p = 0.011). CONCLUSIONS This study demonstrates support for development of formal curriculum on end-of-life issues, and emphasizes the importance of clinical exposure to terminally ill patients to prepare medical students to provide quality end-of-life care.

Teaching residents to read the medical literature: a controlled trial of a curriculum in critical appraisal/clinical epidemiology.

Objective:To teach internal medicine residents key principles of clinical epidemiology that are necessary to read critically the medical literature.Design:Two-phase, non-randomized, controlled educational trial.Setting:University-based training program for residents (PGY-l-PGY-3) in internal medicine.Participants:All 83 residents participated in the trial. Seventy residents completed a test in clinical epidemiology at the end of Phases I and II.Interventions:Residents were assigned to one of eight ambulatory care clinics for half a day each week. A literature-based curriculum in critical appraisal was the subject of a weekly pre-clinic conference for four clinics (Group A). The other four clinics (Group B) had a weekly conference on topics in ambulatory care medicine. At the end of Phase I, both groups were given a test of basic knowledge of clinical epidemiology. The curriculum was then modified with the addition of written questions to emphasize important educational points and to stimulate resident participation. The modified curriculum became the subject of the preclinic conference for Group B, while Group A changed to topics in ambulatory medicine. At the end of Phase II both groups were again tested on basic knowledge of clinical epidemiology.Results:Group B performed significantly better on the second test than on the first, 68.5% vs. 63.3% (p=0.034), while Group A did not improve (64.5% vs. 65.9%). The differences in test scores for Test II minus Test I were+5.17% in Group B and −1.44% in Group A (p=0.019). Twenty-one percent of Group B residents vs. 5% of Group A residents improved their scores by 18% or more.Conclusions:The residency period is a difficult but important time to teach critical appraisal skills. Educational gains may be small and need to be critically evaluated to stimulate the development of more effective educational programs.

Comparison of three methods of gut decontamination in tricyclic antidepressant overdose

The purpose of this study was to prospectively compare the effectiveness of three different gut decontamination methods in 51 patients presenting to an emergency department with tricyclic antidepressant overdose. Patients were randomized to three treatments; Group 1 received activated charcoal, Group 2 received saline lavage followed by activated charcoal, and Group 3 received activated charcoal followed by saline lavage followed by activated charcoal. Baseline characteristics of the three groups did not differ, including Glasgow Coma Scores, age, and mean tricyclic antidepressant levels. Average length of stay in admitted patients was 93.3 hours in Group 1, 107.2 hours in Group 2, and 66.7 hours in Group 3. Of those admitted to an ICU, average ICU time was 66.9 hours in Group 1, 54.1 hours in Group 2, and 34.4 hours in Group 3. Average duration of sinus tachycardia was 20.8 hours in Group 1, 30.8 hours in Group 2, and 32.2 hours in Group 3. Of those requiring mechanical ventilation, average ventilator time was 43.4 hours in Group 1, 24.1 hours in Group 2, and 17.8 hours in Group 3. No statistically significant difference could be shown with respect to the clinical endpoints noted. There were no deaths in any of the groups. All three methods of gut decontamination had similar clinical outcomes.

Patient and Physician Roles in End-of-Life Decision Making

This study is a cross-sectional descriptive survey of randomly selected primary care patients and physicians regarding patient, physician, and family roles in end-of-life decision making. The subjects included 329 adult outpatients and 272 practicing physicians. Physicians were more likely than patients to believe the patient alone was responsible for making end-of-life decisions. Patients were more likely than physicians to believe the physician should provide a recommendation in addition to facts to help the patient make end-of-life decisions. We conclude that patients prefer a more active role for physicians in both decision making and discussion of end-of-life care than do physicians themselves.

Development of a Telehealth Intervention for Head and Neck Cancer Patients

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Initiating and Sustaining a Standardized Pain Management Program in Long-Term Care Facilities

OBJECTIVES To identify current pain management practices in the long-term care setting; and, implement and evaluate a comprehensive pain management program in the long-term care setting. DESIGN An interventional pilot study. SETTING Community-based long-term care facilities. METHODS This study was conducted in two phases. Phase I consisted of interviewing long-term care facility administrators to ascertain current pain management policies and practices. This information was used to develop the Phase II intervention that involved collecting benchmark data, creating or modifying pain policies and procedures, implementing a pain management program and presenting educational programs. MEASUREMENTS Interviews with long term care administrators; facility and resident demographic data; chart audits for pain assessment and management data; pharmacy audits; telephone surveys. RESULTS Pain management policies and practices were inadequate prior to the study intervention. No facilities had policies or procedures that required ongoing (daily, weekly, etc.) pain assessment. Only one facility had mechanisms in place for measuring the presence or intensity of pain in their non-verbal, cognitively-impaired residents. Following the pain management program intervention, pain assessment significantly increased. and treatment for pain was provided for the vast majority of those indicating pain. All sites had a standardized pain assessment program in place one-year post-study completion. CONCLUSIONS Standardized pain management programs are critical to improving pain management in long-term care settings. Improvement in long-term care pain management can be obtained through a comprehensive pain management program that involves staff education, changes in pain policies and procedures, and identifying pain management as a quality indicator.

The Interdisciplinary Curriculum for Oncology Palliative Care Education (iCOPE): Meeting the Challenge of Interprofessional Education

UNLABELLED Background: Interprofessional education is necessary to prepare students of the health professions for successful practice in todays health care environment. Because of its expertise in interdisciplinary practice and team-based care, palliative care should be leading the way in creating educational opportunities for students to learn the skills for team practice and provision of quality patient-centered care. Multiple barriers exist that can discourage those desiring to create and implement truly interdisciplinary curriculum. DESIGN An interdisciplinary faculty team planned and piloted a mandatory interdisciplinary palliative oncology curriculum and responded to formative feedback. SETTING/SUBJECTS The project took place at a large public metropolitan university. Medical, nursing, and social work students and chaplains completing a clinical pastoral education internship participated in the curriculum. MEASUREMENTS Formative feedback was received via the consultation of an interdisciplinary group of palliative education experts, focus groups from students, and student evaluations of each learning modality. RESULTS Multiple barriers were experienced and successfully addressed by the faculty team. Curricular components were redesigned based on formative feedback. Openness to this feedback coupled with flexibility and compromise enabled the faculty team to create an efficient, sustainable, and feasible interdisciplinary palliative oncology curriculum. CONCLUSION Interdisciplinary palliative education can be successful if faculty teams are willing to confront challenges, accept feedback on multiple levels, and compromise while maintaining focus on desired learner outcomes.

Palliative care case management: increasing access to community-based palliative care for Medicaid recipients.

Purpose: The purpose of this pilot project was to integrate palliative care principles and practices into the day-to-day operations of a Medicaid managed care provider. This was accomplished through the following five activities: (1) employment of an experienced palliative care nurse and social worker to serve as expert role models and consultants to the case management staff; (2) development of a palliative care training curriculum for case managers; (3) provision and evaluation of the training; (4) identification of appropriate patients, provision of palliative care case management (PCCM), and tracking of outcomes; and (5) development of a resource/reference manual for case managers. Primary practice setting: The project involved a managed care organization providing Medicaid services to patients residing in both urban and rural settings. Findings/conclusions: Expert staff was hired and modeled effective PCCM. This, as well as the training program, had significant influence on both the palliative care knowledge and attitudes of existing case managers. Involved patients demonstrated improved symptom management and satisfaction with care. Patient scenarios demonstrated desirable outcomes in healthcare utilization, and timely, appropriate hospice referrals were realized. Implications for case management practice: Integrating PCCM into the practices of a provider of Medicaid managed care can result in positive patient outcomes, improved utilization of healthcare services, and related savings for the managed care provider. Such a program can increase access to community-based palliative care for Medicaid recipients with life-threatening illnesses. PCCM can address the multiple needs of younger patients with serious illness who are not yet ready to forego curative efforts.

Improving medical graduates’ training in palliative care: advancing education and practice

The needs of an aging population and advancements in the treatment of both chronic and life-threatening diseases have resulted in increased demand for quality palliative care. The doctors of the future will need to be well prepared to provide expert symptom management and address the holistic needs (physical, psychosocial, and spiritual) of patients dealing with serious illness and the end of life. Such preparation begins with general medical education. It has been recommended that teaching and clinical experiences in palliative care be integrated throughout the medical school curriculum, yet such education has not become the norm in medical schools across the world. This article explores the current status of undergraduate medical education in palliative care as published in the English literature and makes recommendations for educational improvements which will prepare doctors to address the needs of seriously ill and dying patients.