Palliative Care and Geriatrics: Curriculum Development and Implementation

1. Palliative Care and Geriatrics:Curriculum Development and Implementation James Hallenbeck, MD Medical Director, VA Hospice Care Center and Stanford Hospice

2. Questions • Why teach palliative care in the nursing home? • Will physicians-in-training be receptive? • How do I design a curriculum? • How do you teach in this environment?

3. Why Teach Palliative Care in the Nursing Home? • Great overlap between geriatrics and palliative care • Palliative/EOL care needs are significant • Gives focus to nursing home/geriatric rotation • Certain palliative care principles difficult to teach in other environments

4. Teaching in the Nursing Home-Special Opportunities • Relatively stable population • Multiple palliative issues to address • Patients often have time to talk/teach • A great place to experience that there is more to healthcare than acute care

5. Will Physicians-in-training Be Receptive? • Geriatric training required for internists- nursing home training is not • Barrier of perception- there’s nothing to learn: ‘just old people waiting to die…” • Bad news: we have to work harder to overcome this barrier • Good news: residents are receptive, if they have a good educational experience

6. Physician Education and Palliative Care • 90% of medical students have some training • Usually didactic- focus on ethics • Symptom management rarely taught • Housestaff education largely part of the “resident sub-culture” • Training/modeling by attending physicians uncommon

7. Intern Prior Experiences With Death • 6% reported death of 1st degree relative • 85% reported some training in EOL care • only one intern reported any training in symptom management • 55% cared for dying patients only in acute care • 59% had never cared for a dying patient without an IV N= 27

8. Palo Alto VA Intern Hospice StudyLack of EOL skills • Pain 2.00 .92 • Terminal dyspnea 1.81 .79 • Nausea and Vomiting 2.41 1.05 • Physical Changes in Dying Process 1.70 .72 • Psychological Changes in Dying Process 2.11 .89 • Grieving and Dying 2.56 1.12 1= Knew a little, 5= Knew a lot Mean SD

9. Scale: 1= Strongly Disagree, 5= Strongly agree ITEM Pre Post P < 0.001 for all

10. A Lack of Attending Modeling • 22% had never witnessed an attending discuss advanced directives • 19% had never witnessed an attending share bad news • 44% had never witnessed an attending tell a family member of a death

11. Designing a Curriculum • Identify your own educational needs- retool as needed • Address learner’s needs/goals • Be explicit about your goals for the learner • Don’t reinvent the wheel • Find and utilize existing educational material

12. Identifying Your Own Educational Needs • Strengths: your prior training and experience is a precious resource • Weaknesses: • Few have been well trained in palliative care • Even those who have been trained have areas of relative strength and weakness

13. Educational Resources: • AMA EPEC (Educating Physicians about End of Life Care) Program • American Academy of Hospice and Palliative Medicine • Published curriculum • UNIPACS • Other courses: SFDP, Harvard • Websites: growthhouse.org, eperc.mcw.edu • Textbooks: Oxford Textbook of Palliative Medicine

14. Adult Learners Are Not Blank Slates • Most residents have their own goals going into a rotation- identify and address them! • Common goals: • Pain, non-pain symptom management, learning what life is like in a nursing home • Uncommon goals: • Learning how to do the definitive incontinence work-up • Learning the fine art of disimpaction

15. What Are Your Goals for Learners? • Be explicit at beginning of the rotation • Do not try to convince them that they unconsciously want to be nursing home physicians • Do include both medical and non-medical goals

16. Possible Goals • Pain management • Non-pain symptom management • Economics/system issues of nursing home care • What life is like in the nursing home • For professionals and residents • Communication skills • Bad news, goal setting, family conferences, conflict resolution • Self-reflective goals • How do they feel about growing old and going to a nursing home?

17. Domains of Palliative Care Pain Management Non-pain Symptom Management Communication Ethics/Difficult Decisions Psychosocial, Spiritual Care System issues

18. Educational Resources for Learners • Published curricula, selected articles • Your own/colleagues handouts • Videos, websites • Patients • Families • Other staff Don’t try to go it alone!

19. Teaching in the Nursing Home-Tricks of the Trade • Link didactic instruction to clinical care • Setting a theme • Establish different learning experiences • Nurses aide for a day • Aide to different specialty, such as PT • ? Patient for a day • Journal or other writing • Role play communication skills • Role modeling Be Creative!

20. Role ModelingThe Challenge... • How does the teacher immerse himself or herself in the role without loosing the learner? • Specifically, how does the teacher facilitate the learner’s involvement with the content, if the teacher is ‘on stage’?

21. T-L-C EDUCATIONAL MODEL TEACHER LEARNER CONTENT

22. TEACHER IMMERSED IN CONTENT TEACHER LEARNER PATIENT Danger of role immersion- links to learner weakened

23. Role ModelingThe Context Questions to ask... • Part of continuity experience? • How is modeling linked to didactic session(s) • Who are the learners? • ? Mixed skill levels or homogenous • Special learning opportunities? • Unusual situations, patients in nursing home

24. Setting a theme • Useful especially if seeing patients in series • May link to didactic session, special learner needs and learning opportunities • Assign learner tasks within a theme • Examples: • “Why is this patient here?” • “Look at the walls and tabletops” • “What does home mean to this patient?” • “How do different confusional states differ?”

25. Before seeing the patient • Reinforce theme, if present • Collect data • Set specific tasks- • That you wish to accomplish • Tasks for learners

26. The Patient Encounter • Goal- immerse yourself totally in the relationship, but continue to involve the learner • Analogous to a good actor- must become the role, but in a manner that allows the audience to see • This so difficult- it’s a life-time practice

27. The Echo • Definition: A verbal reflection of internal thought processes • Method: • Explain what you are doing • Filter what you don’t want patient to hear • Interpret what you mean so patient/family can understand • Example: patient with red-eyes

28. The Lateral Pass • Definition: A means of changing roles to facilitate new forms of interaction • Method: make patient (or learner) the teacher • Examples: • “You’re the one with pain, what can you teach us about pain (or dying)”

29. After the Patient Encounter • Opportunity to re-connect learner to content • “What questions do you have?” • Opportunity to evaluate • “What did you see?” • “What was I trying to show when I…” • Time to comment- fill in the blanks • Time to reinforce/summarize

30. SUMMARY • The nursing home is an excellent place for teaching knowledge and skills rarely taught elsewhere • Teaching can be very rewarding and appreciated by physicians in training • Doing the job well requires a solid knowledge base, planning and skill