Hospice and Palliative Care in the Medical School Curriculum: An Integrated Approach

1. Hospice and Palliative Care in the Medical School Curriculum: An Integrated Approach James Richter, MSIV University of Nevada SOM Curriculum Committee Presentation

2. Current Curriculum - Year I • “Hospice Care & Spirituality” is a two hour lecture during Human Behavior which includes a panel of speakers: pastor, medical director of the local hospice, hospice nurses and a psychologist. • “The Role of the Family Meeting” is a one hour lecture during Human Behavior in which the family of a critically ill child joins the class for a round-robin discussion on the dynamics of the family and how illness has affected them. Both parents, 2 siblings, grandparents, and two aunts of the 11 yea- old boy were present.

3. Current Curriculum - Year I • Anatomy Memorial Service – This activity is planned by the members of the first year as a memorial to those who donated their bodies through the Anatomic Donation Program. Family members, faculty, and all members of class are in attendance.

4. Current Curriculum - Year II • Community Medicine – this course contains one two-hour lecture that includes a cursory discussion about hospice as a resource, the enrollment (through Medicare) and reimbursement, and the mention of a local hospice agency.

5. Current Curriculum - Year II • Pharmacology – Currently includes almost 17 lectures covering Opioid Analgesics and Antagonists, Anti-Inflammatories, and Autocoids and Autocoid Antagonists. There is virtually no mention of the unique role of some these agents at the end of life.

6. Current Curriculum - Year III • Practice of Medicine Case Conferences – There are 21 conferences scheduled, of which three are EPEC modules. There is not adequate time allowed for discussion, interaction with the presenter, or any student participation.

7. Current Curriculum - Year IV • Electives – Currently there are electives in Hospice and Palliative Care Medicine in both Reno and Las Vegas for fourth year medical students. These represent two of the 46 in-state electives through the department of Internal Medicine.

8. Areas for improvement… • Strengthen existing curriculum through the addition of “special topics” lectures to replace less relevant items in the syllabus. • Identify interested faculty to help incorporate specific topics in existing course content.

9. Areas for improvement… • Expand hospice themes into PBL and Clinical Problem Solving cases and assess student performance on these modules. • Use Year I and II to introduce hospice themes into the basic sciences.

10. Areas for improvement… • Identify and modify existing learning issues in hospice and palliative care which are ineffective. • Develop an exam to be taken at the end of Year II to measure student performance on the content that is covered.

11. “Surgeons Must Be Very Careful” Surgeons must be very careful When they take the knife! Underneath their fine incisions Stirs the Culprit – Life! Emily Dickinson

12. Recommendations – Year I • Initiate a Death & Dying Interest Group under the auspices of the existing AMSA chapter to bring interested student together. There will also be a faculty sponsor to help the student develop and agenda for the year.

13. Recommendations – Year I • Add a PBL case to the existing schedule of 13 cases, such as the one developed at the EOL Fellowship. An answer key will also need to be made available for the facilitators, and the course coordinator will schedule time during the beginning of the year facilitator orientation to address the new case and review some the the learning issues that are unique to this case. The PBL can be edited and focused for use the following year.

14. Recommendations – Year I • “To Live Until I Die” – This movie can be substituted for the two hour Human Behavior Lecture or added to the syllabus. The one hour movie will be followed by 45 minutes of small group discussion during which students will have an opportunity to write a short essay focusing on their reaction to and feelings about one of the featured people. These essays will be collected and returned during the part of the course in which “Writing as a Therapeutic Intervention” is covered.

15. Recommendations – Year I • “Physiology of Dying” – this lecture can be featured at the end of the semester of Physiology as one of the overview/special topics lectures that are included annually in the syllabus. This two hour lecture will be hosted by a guest hospice physician to include: • Pulmonary Symptoms/COPD • Renal Failure • Pressure Ulcers • GI Symptoms

16. Recommendations – Year II • Critical Problem Solving – the course meets every other week all year, during which students do a PBL case on the computer using cases developed through Southern Illinois University’s PBL project. An effort will be made to include at least two cases in which the management of the patient includes issues of hospice referral, the need for a psycho-social-spiritual evaluation and intervention, and pain management. The student will need to consider these components in their management write-up order to earn honors in the case.

17. Recommendations – Year II • Introduction to Patient Care II – This course currently is one semester and meets weekly for 3 hours. Because communication skills and establishing a physician-patient relationship are at the core of the course as students prepare for the third year, one class period may be devoted to the interaction between the student and a dying patient. The first hour can focus on delivering bad news (using the EPEC presentation), and the other two hours a role play between the student and a dying patient. These roles can be written up and assigned so that small groups are each facilitated by their fourth year mentor.

18. Recommendations – Year II • Currently Introduction to Patient Care II does not cover “pain as the fifth vital sign”. Introducing the pain scale and the importance of assessing pain in verbal, non-verbal, and comatose patients will be emphasized. Students will be given a pain scale to use on their clinical interactions, and will be included as criteria for the final exam on the “model patient”. Pain histories, pain contracts, and pain management techniques will also be covered.

19. Recommendations – Year II • Pharmacology – addition of a new lecture at the end of the semester in the overview/special topics section of the syllabus for “Pharmacology at the End of Life – Managing Symptoms in a Palliative Care Setting” to include: • Role of Morphine and other Opiates • Palliation versus Cure – d/c’ing medications • Myths about narcotics • The importance of pain control • Clearing secretions • Be kind to the kidneys

20. Recommendations – Year III • Practice of Medicine Case Conferences – consider dropping two of the three EPEC components. Keep the Opioid Management/Conversion Exercise module, but augment the canned presentation with a list of work problems that students can do individually/small groups with the help of the facilitator. These problems should emphasis basic concepts in opiate conversions and the importance of being able to use these correctly.

21. Recommendations – Year III • Surgery – Journal Club using the article “Beyond Symptom Management: Physician Roles and Responsibilities in Palliative Care” . Because the department of surgery has been so open to suggestions for improvement of the curriculum for medical students, this article has been suggested as one for the bi-monthly journal club. Third year students on this rotation can read and discussion this article as one of three scheduled for that day’s session. The theme of the paper is “Caring for people approaching death will always draw on the art and humanity of the practitioner. The responsibility of ensuring excellent medical care for the dying patient lies with the attending physician”.

22. Recommendations – Year III • Surgery – Journal Club using the article “Should There be a Choice for Cardiopulmonary Resuscitation When Death is Expected? Revisiting and Old Idea Whose Time is Yet to Come”. The theme of the paper is: for patients who are irreversibly ill and expected to die soon, should there even be a choice for a DNR order and is it morally right to impose such a decision on the patient or proxy?

23. Recommendations – Year IV • Electives – Continue to offer these selections.

24. EOL Lunch Series… Fall, 2003 • Welcome lunch – An overview of the year’s activities and survey about students attitudes about EOL issues and self-reflection on death and dying (to be used again at the end of the year for assessment). • Second Session – Hospice Panel – Presentation by the local hospice agency which will cover role of hospice, members of the team, services provided, and hopefully a relative of a former patient.

25. EOL Lunch Series… • Third Session – Legal and Ethical Issues in Death & Dying – this will be lead by a member of the local Hospital Ethics Committee and will be a case-based presentation to cover the role of an advance directive, making ethical decisions, and the difference between legal and ethical decision making.

26. EOL Lunch Series… • Spring, 2004 • Session Four – “Wit” movie night – this will be an informal gathering for students. Snacks will be provided and students will be encouraged to write down phrases that strike them during the movie. These will be the basis for small group discussion following the film for 30 minutes of so. Faculty will be invited to facilitate the debriefing.

27. EOL Lunch Series… • Session Five – “A Philosophical Exercise on Death & Dying”. This session will be modeled after the EOL exercise and moderated by our faculty chaplain with a handout to be reviewed before the session. This session will cover • The Five Wishes • Completing your own Death Certificate • Reflections covering your own experiences with death

28. EOL Lunch Series… • Session Six – “Taking a Spiritual History”. This session will also be lead by our faculty chaplain and will cover the elements of a spiritual history with items taken from “Taking a Spiritual History to Understand Patient More Fully”.

29. Diversity Week 2004 • The Death & Dying IG will contribute a speaker to this week-long series which highlights important issues of diversity and their relationship to the practice of medicine. A presentation that covered such issues as described in “Palliative Care in African American Communities” would be an excellent addition to those programs sponsored by other interest groups.

30. Faculty Support • Dean for Medical Education • Assistant Dean for Medical Education • Course Coordinators: Human Behavior, Clinical Problem Solving, Introduction to Patient Care, and Practice of Medicine • Department of Surgery

31. Summary of Goals • Expansion of topics related to Hospice and Palliative Care principles into the curriculum for all four years. • Use of writing assignments, small group discussions, role play, special lectures, clinical skills development, mentors and journal clubs. • Curricular improvements supported by extra-curricular activities to meet the needs of interested students and foster the development of a special interest group under the umbrella sponsorship of AMSA.

32. Bibliography • See materials attached to this proposal

33. EOL Fellowship Goals • Maintain contact between the Fellows, and consider using the AMSA Death & Dying list serve to facilitate that effort. • Contribute the The New Physician an article or reflection by members of this group about our experiences. • Share the Hands Project photos with my school during the Diversity Week Celebration.

34. I am almost done here… • “Call in Death as a Consultant.” Oscar London, M.D. from his book Kill as Few Patients as Possible

35. My appreciation to… • Dr. Veach, Dean for Medical Education for his support of my participation in this experience. • Dr. Peggy Dupey, Assistant Dean for Student Affairs, for helping to champion this issue and the University of Nevada. • UNSOM Curriculum Committee for considering this proposal.

36. My appreciation to… • Lorie Hedges, her more-than-able assistant Rachel Hedges, the medical directors and staff of Horizon Hospice, Hospice of Illinois, and Vitas Hospice, Chicago for making this experience so very worthwhile. • The patients who allowed us the privilege of being part of their care and their journey at the end of life. They and their loved ones have been careful teachers.