Whitney Palmer

Focus on Palliative Care Education Grows

Published in the July 2004 AAMC Reporter

At the end of a hospital hallway in a dimly lit room, a tired, grief-stricken family huddles close to the bedside of the patient, a husband and father. They listen intently as the doctor tells them the chemotherapy and radiation treatments have failed to eradicate the cancer, and there is nothing more that can be done except to make the patient as comfortable as possible.

Whether the disease is cancer or another fatal condition, hundreds of thousands of people die slowly each year, a nightmare no family wishes to undergo. Even when a patient’s condition is terminal, physicians are still responsible for the patient’s quality of life until he or she succumbs to the illness. In recent years, with the growth of hospice care, more and more families expect doctors to demonstrate good faith efforts in end-of-life care, also known as palliative care.

Across the United States and Canada, several medical schools and researchers have implemented palliative education programs and outlined the characteristics  of effective, compassionate end-of-life care. Students at Mount Sinai School of Medicine in New York learn palliative care methods at the Hertzberg Palliative Care Institute while University of California-San Francisco (UCSF) students study at a new symptom management and palliative care program at the school’s Comprehensive Cancer Center.

“We’ve had a startling and consistent positive response to our program because it’s the first place some students learn how to relieve suffering and are given the knowledge and skills to help these patients,” said Diane Meier, M.D., director of the Hertzberg Institute. “I’ve had one student come up to me and say, ‘Now I feel like a good doctor.'”

Dr. Meier is also a professor in Mount Sinai’s geriatrics and medicine department, as well as the director of its Center to Advance Palliative Care.

Acquiring Compassion

The Hertzberg Institute, which received original funding from the Project on Death in America, integrates palliative care instruction through all four years of medical education in the geriatrics and adult development department. As part of the program, students spend increasing amounts of time with dying patients each year.

During the first and second years, students studying hematology and oncology interact with patients experiencing sever illness, learning how they cope and what they need to be comfortable. Patients who are physically able to speak to classes and tell them about their experiences, both good and bad, with hospital care.

Third-year students complete a mandatory rotation, including six lectures outlining palliative care fundamentals. They form small groups, emphasizing role-playing activities that they discuss later with a faculty member.

J. Andrew Billings, M.D., associate professor of medicine at Harvard University, agreed that providing instruction in proper palliative care is essential throughout medical education. Dr. Billings works in palliative care at Massachusetts General Hospital.

“You have to have the appropriate curriculum in end-of-life care at all levels of education,” he said. “All physicians and clinical areas deal with death and dying, and they need to be familiar with the basics.”

Often  medical students and practicing physicians indicate they are uncomfortable treating dying patients, Dr. Billings said. Some doctors worry ill patients and their families receive substandard care due to the physician’s lack of confidence.

The Hertzberg Institute has taken additional steps to give students more assurance and enhanced palliative education. Fourth-year students can choose to participate in an elective rotation with the Palliative Care Consultation Service. Students see patients first and evaluate them before passing along a review and recommendation to the attending physician.

In addition, beginning this month Dr. Meier said Hertzberg will initiate a new fellowship program for post-graduate hematology-oncology students interested in becoming dually qualified in palliative care. The fellowship provides one-on-one mentoring with national palliative care experts, as well as opportunity to provide care in a variety of settings, including ambulatory center, hospices and nursing homes.

Training students to specialize in palliative care could relieve primary care physicians of palliative care physicians of the palliative care responsibility and improve service for dying patients, Dr. Meier said. Tending to the needs of these few patients sometimes puts a strain on the limited time physicians have.

“Some just don’t have the time as primary physicians to be able to provide palliative care, and their willingness to do it is highly unrealistic,” Dr. Meier said. “But if you have physicians trained in palliative care, they take the pressure off their colleagues. So, we’re rounding out the skill set of the whole team.”

Empowering Patients

A team of researchers at the University of Toronto conducted a three-month experiment in 2002 that focused on improving palliative care methods by concentrating on patient comments and needs. Jeff Powis, a fourth-year Toronto medical student, led the project to help physicians improve palliative care based on patient requests for better pain management or symptom control.

During the experiment, Powis functioned as a liaison between 36 families and their physicians, relaying questions, concerns and desires. He said it was his job to ake sure families felt their voices were being heard and to keep doctors aware of patients’ comfort needs.

“Families told me they saw me doing something that needed to be done,” he said, referring to his hallway briefings with physicians. “It gave [the families] a sense of empowerment while I was helping doctors systemize their palliate care.”

By asking patients to prioritize what three things they needed most, such as help with daily activities or improved access to nurses, Powis said he truncated the time doctors spent trying to discover what the patient needs from 30 minutes down to only a few. The three-month trial determined end-of-life care is better when it focuses o patient requests.

Patients and families want someone to listen to their concerns and take action to relieve pain and stress, so teaching students to listen to patients is the most important aspect of palliative care instruction, Powis said. But effective end-of-life care does not rest solely on physicians. It must be a combined effort of everyone involved in healthcare.

Opening Doors

Peter Singer, M.D., University of Toronto professor of medicine and director of the school’s Joint Centre for Bioethics, agreed. The days of shuffling dying patients to the end of a hospital wing have passed, and the time has arrived for doctors, hospital administration and hospital health workers to join in palliative care.

“Talk about improving end-of-life care is cheap,” Dr. Singer said. “You have to make changes to be really effective. If every medical resident spent two weeks doing what [Powis] did, we’d have a generation of physicians appropriately prepared to care for patients and families.”

Toronto is not alone in its efforts to improve palliative care with hands-on involvement. On July 1, UCSF opened the doors to a collaborative effort between its Cancer Center Program in Symptom Management and Palliative Care and the UCSF Comprehensive Cancer Center. The partnership, involving students, a pharmacist, a nurse and a social worker, will share the responsibilities of controlling symptoms and managing pain. The original cancer center program, known as the comprehensive care team, only functioned as a consultative and advisory group for physicians.

Social workers skilled in psychological assessment, communications and support meet with the patients, helping them secure home care services if they need it. But they also discuss the patients’ emotions about dying and try to open communication channels between the sick and their families.

Not everyone involved with end-of-life care is ready to sing the praises of palliative care teams. Some observers believe such groups are detrimental to the movement that advocates greater palliative care training.

Palliative care teams that focus on end-of-life care are hindering the push for palliative care education across the medical industry, said Kerry Bowman, Ph.D., clinical ethicist at Mount Sinai Hospital in Toronto and professor at the University of Toronto’s Medical Joint Centre for Bioethics. Establishing these groups undermines the need for all physicians to have these skills.

“Everything is complicated by creating palliative care teams,” Dr. Bowman said. “If a referral is made to a palliative care worker, then the physician feels as though he’s off the hook. We’re never off the hook.”

But placing students in a team environment where they are faced with dying patients is the best way to teach them the proper

palliative care skills, said Michael Rabow, M.D., the UCSF program principal investigator. This exposure will also help them face their discomfort with patients who are beyond the reaches of medicine.

“If you look at palliative care as the elephant in the room, the best thing to do is to talk explicitly about the elephant in the room,” he said. “The best thing is not to pretend that something meaningful doesn’t happen through palliative care.”

Palliative care education should exist on two levels, he said. Every physician should have a basic understanding of how end-of-life care can best serve patients. Because the medical community has put a major emphasis on a “good death,” Dr. Rabow said palliative care should also become a specialty, giving patients the opportunity to choose a palliative care expert as they approach death much as they would select a cardiologist for heart surgery.

Before beginning any palliative services, UCSF program participants assess the patients during any treatment they receive to find out what additional services they might need, such as sessions with a social worker. Palliative care can be much more effective if the groundwork is established early rather than postponed until death becomes inevitable, he said.

Patients also have the opportunity to express their emotions and frustrations through art. Rabow’s palliative care team includes a clinical artist trained to assist dying patients with their emotional needs. The artist, who is also a cancer center staff member encourages patients to articulate their feelings through pictures giving them a unique outlet to channel their fears.

“Often, patients will draw something that they might not actually say directly,” Dr. Rabow said. “But the pictures can be used to begin a conversation that might not have happened otherwise, and patients and families will begin to connect with their emotions.”

The Hertzberg Institute and the University of Toronto’s Joint Centre for Bioethics are part of a small cadre of academic institutions beginning to recognize the importance of improved palliative care in both countries. With too many students receiving far too little  in this type of medical treatment, current practitioners must prepare the next generation of physicians to care for dying patients. While palliative care may not carry a high profile, dying with dignity is an important component of the medical ethos,” Dr. Bowman said.

“End-of-life care is not sexy. You’re not going  rich, you’re not going to become famous,” he said. “If you’re looking for fame and wealth, there are sexier areas, but the public is demanding better palliative care. They’re asking for more humane, comprehensive, inclusive medical care.”

April 1, 2010 - Posted by wjpalmer | 1, Family, Healthcare | caring for the dying, end-of-life care, healthcare at end of life, palliative care, palliative care teams, the Hertzberg Institute, the University of Toronto Joint Centre for Bioethics