Steven Radwany

The Promoting Effective Advance Care for Elders (PEACE) Randomized Pilot Study: Theoretical Framework and Study Design

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohios community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagners Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.

Poetry as Self-Care and Palliative Care

These three poems reflect the joint effort between the Wick Poetry Center at Kent State University and Summa Health System’s Palliative Care and Hospice Program. Two Wick facilitators meet monthly with a group of eight to ten palliative care providers to jointly and individually reflect on trigger poems and write their own. The act of assisting health care professionals in writing poetry offers a unique form of self-care for palliative care providers while honoring the patients and families they serve. This method and medium serves two distinct purposes: process and pause. In process, the writing allows the health care providers to reflect on, evaluate, and illuminate the experience of caring for individual patients. Those patients may elicit emotions, memories, and dynamics that aren’t apparent at the time of initial encounter, and can only be reflected on and appreciated later. The pause allows the team and the individual health care provider to honor a patient and/or a family whom they have served. The business of working in health care often prevents one from stopping to honor and appreciate patients and families, the richness of their lives, and the challenges they often face with such grace and dignity. The act of writing poetry provides the opportunity to deepen what we learn from them. Why poetry? Team members could write reflective narratives regarding patients and experiences, but prose itself can be intimidating. As one participant said, ‘‘Writing narrative feels as if you have to spit out a fully formed and finished four bedroom house on paper. Poetry provides team members the opportunity to pitch a tent on a thought, an idea, or an image, and build from there. This allows the details to collect, the emotions and memories to be attached, and the structure to grow.’’ Poetry also has the unique ability to express emotional experiences that the listener of the poetry has known but may have never before articulated. When this is done in a group, the discussion and sharing that follows can facilitate a deeper processing of the experience. At its root, self-care is a process of maintaining and/or restoring one’s wholeness. Stress and our characteristic response to it often leads to a kind of splintering in which we alienate a part of ourselves so that we can continue to function. The classic compartmentalization that many health care providers practice in order to wall off distressing or toxic experiences so that they do not ‘‘contaminate’’ the rest of their lives can, over time, lead to self-alienation and burnout. As if one could really wall off a part of the self from the whole self! Indeed, we are more likely to harm ourselves and others when we are splintered than when we are awake to our own pain and challenging experiences. Poetry has a special capacity to facilitate the reintegration of ignored aspects of ourselves so that we can again function as whole, fully integrated persons. Utilizing poetry workshops as a prescription for self-care may not be for everyone, so multiple options must be available to team members. But if we don’t believe in the power of poetry, then we don’t believe in the power of words. If we don’t believe in the power of words, then we have never had a patient or family retell repeatedly a single turn of phrase from the physician or nurse days, months, or years later, upon which the entire course of their loved ones illness and demise appeared to hang. It often seems as if our professional identities do hang on a few such words which can be turned for the better when words are used to honor and heal.

Fellowship Directors’ Program—What Keeps us Awake at Night: Addressing the Challenges of Palliative Medicine Fellowship Programs as the Next Accreditation System and the Match Become Reality (P04)

Ignite your leadership potential. Financial DecisionMaking Approaches is designed to equip hospice and palliative medicine physicians with foundational principles in financial management to increase their understanding of institutional or organizational financial reports. This course will provide an introduction to financial concepts and terminology followed by an exploration of cost analysis and resource allocation using sample financial tools and documents, case studies, and scenarios to provide practical relevance for HPM physicians. This preconference program is offered in partnership with the American Association for Physician Leadership (Association) and presented by Association faculty. This session applies to all physician leaders and practice settings looking to enhance their financial management understanding and decision-making for their organization. Primary leadership competencies addressed in this program include financial acumen and resource management. AAHPM Ignite is one of three sessions included in the AAHPM Leadership Forum. AAHPM and the American Association for Physician Leadership have designed a comprehensive leadership training program that offers a variety of learning opportunities and varied environments, including face-to-face didactic instruction and Web-based self-study. You can create your own customized and flexible learning pathway and select content based on your unique leadership development goals and career pathway. Learn more at aahpm.org/career/leadership.

Add Your Voice: Vetting the Entrustable Professional Activities for HPM Physicians (TH335)

1994 to 2003, the PDIA created funding initiatives in professional and public education, the arts, research, clinical care, and public policy that transformed care for patients living with serious illnesses in the United States. Four PDIA Awards will be presented: the AAHPM PDIA Palliative Medicine National Leadership Award, the AAHPM PDIA Palliative Medicine Community Leadership Award, the HPNF PDIA Nursing Leadership Award in Palliative Care, and the SWPHN PDIA Career Achievement Award. Award recipients will participate in panel presentations on topics such as career trajectory, lessons learned, and take-away ‘‘pearls’’ for the attendees.

The Impact of a Palliative Care Consult Service on Patient Code Status and Discharge Outcomes (702)

Objectives 1. Discuss Palliative Care Consult Service functions with regard to Advance Directives and provider documentation of code status. 2. Describe the transition from full code to full medical management to comfort care only. 3. Explain the relationship between code status, discharge planning, and outcome. I. Background. Hospital inpatient Palliative Care Consult Services (PCCS) assist patients and families in establishing goals of care; arranging for continued medical care; and discharge consistent with those goals. Outcomes commonly include advance directives or DNR orders. II. Research Objectives. This study examines the impact of palliative care consults on changes in patient code status and discharge outcomes. III. Methods. Data were obtained from the PCCS administrative database on a sample of patients for whom code status change was documented. Descriptive statistics were conducted on reasons for the consult, code status changes, days between consult and code status change, and discharge outcomes. IV. Results. Code status changed to Comfort Care Only (CCO) for 539 patients; 46% from DNR CCA (a designation specific to Ohio, which requires full medical management until cardiorespiratory arrest at which time CCO takes effect) and 54% from full code. End-of-life issues were the reason for 75% of consults. Discharge status for 71% was death and for 18% hospice care. Code status changed on average 2.2 days after consult, 51% occurring on the same day. There were 435 patients who became DNR CCA; 428 (98%) were full code when the consult was requested. End-of-life issues was the reason for 67% of consults and establish goals of care for 16%. Discharge status for 47% was death and for 22% hospice care. Code status changed on average 1.4 days after consult, 62% occurring on the same day. V. Conclusion. The PCCS facilitates establishing goals of care and initiates appropriate care for patients with advanced disease. Many PCCS requests involve helping dying patients and families with end-of-life issues, resulting in code status changes and/or hospice enrollment. VI. Implications for Research, Policy, or Practice. A hospital inpatient PCCS supports patients and families facing end-of-life decisions and care, helping assure that patients receive medically appropriate care that is consistent with their goals.