Stuart Farber

Issues in end-of-life care: patient, caregiver, and clinician perceptions.

CONTEXT Review of published research indicates the need to better incorporate patient and caregiver perceptions when providing end-of-life (EOL) care. Although considerable research regarding patient and caregiver experience of EOL has been done, little research has studied patients, caregivers, and clinicians as a connected system. OBJECTIVE To study the perceptions of patients, caregivers, and physicians who are already connected with one another in an EOL care experience. DESIGN Qualitative study consisting of in-depth, open-ended, face-to-face interviews and content analysis. SETTING Community family practice residency programs in rural and urban settings in the Affiliated Family Practice Residency Network of the Department of Family Medicine, University of Washington School of Medicine. PARTICIPANTS Forty-two patients and 39 caregivers facing EOL were interviewed either alone or together after referral by their physicians. Additionally, results of previously published findings from interviews with 39 family practice faculty were included. OUTCOME MEASURES Perceptions of participants on EOL issues. RESULTS Participants identified four primary issues related to their experience of EOL care: awareness of impending death, management/coping with daily living while attempting to maintain the management regimen, relationship fluctuations, and the personal experiences associated with facing EOL. Participants expected their physicians to be competent and to provide a caring relationship. CONCLUSIONS Awareness of these crucial patient and caregiver EOL issues and expectations and how they differ from clinician perspectives can assist clinicians to appropriately explore and address patient/caregiver concerns and thereby provide better quality EOL care.

Incorporating palliative care into primary care education

SummaryThe confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity—students’ clinical years—to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

Cost savings vary by length of stay for inpatients receiving palliative care consultation services.

BACKGROUND Cost savings associated with palliative care (PC) consultation have been demonstrated for total hospital costs and daily costs after PC involvement. This analysis adds another approach by examining costs stratified by hospital length of stay (LOS). OBJECTIVE To examine cost savings for patients who receive PC consultations during short, medium, and long hospitalizations. METHODS Data were analyzed for 1815 PC patients and 1790 comparison patients from two academic medical centers between 2005 and 2008, matched on discharge disposition, LOS category, and propensity for a PC consultation. We used generalized linear models and regression analysis to compare cost differences for LOS of 1 to 7 days (38% of consults), 8 to 30 days (48%), and >30 days (14%). Comparisons were done for all patients in both hospitals (n=3605) and by discharge disposition: survivors (n=2226) and decedents (n=1379); analyses were repeated for each hospital. RESULTS Significant savings per admission were associated with shorter LOS: For stays of 1 to 7 days, costs were lower for all PC patients by 13% (

Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools.

2141), and for survivors by 19.1% (

Confidence intervals for affinity constants, heterogeneity indices and concentration of reactive sites estimated by the 50% ammonium sulphate method on rat's anti-DNP sera☆

2946). For stays of 8 to 30 days, costs were lower for all PC patients by 4.9% (

TNEEL Workshop: Interactive Methods for Teaching End-of-Life Care

2870), and for survivors by 6% (

Hospice volunteer training for health science students: an academic medical center-hospice community partnership.

2487). Extrapolating the per admission cost across the PC patient groups with lower costs, these programs saved about

Technology survey of nursing programs: implications for electronic end-of-life teaching tool development.

1.46 million for LOS under a week and about

Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions

2.5 million for LOS of 8 to 30 days. Patients with stays >30 days showed no differences in costs, perhaps due to preferences for more aggressive care for those who stay in the hospital more than a month. CONCLUSION Cost savings due to PC are realized for short and medium LOS but not stays >30 days. These findings suggest savings can be achieved by earlier involvement of palliative care, and support screening efforts to identify patients who can benefit from PC services early in an admission.