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Palliative Care and Geriatrics: Curriculum Development and Implementation

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Title: Palliative Care and Geriatrics: Curriculum Development and Implementation


1
Palliative Care and GeriatricsCurriculum
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- theres 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
N 27
  • 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

8
Palo Alto VA Intern Hospice StudyLack of EOL
skills
1 Knew a little, 5 Knew a lot
Mean SD
  • 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

9
ITEM Pre Post
Scale 1 Strongly Disagree, 5 Strongly agree
Working in a Nursing Home as a physician would be undesirable 3.9 2.8
Working with terminally ill patients in Hospice would be undesirable 3.3 2.3
Exposure to and training in the care of Nursing Home patients is important 3.6 4.6
Exposure to and training in the care of terminally ill (Hospice) patients is important 3.7 4.8
Some training in the care of Nursing Home patients should be mandatory for all internists 3.6 4.6
Some training in the care of terminally ill patients should be mandatory for all internists. 3.8 4.6
P lt 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 learners needs/goals
  • Be explicit about your goals for the learner
  • Dont 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

Dont 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
    learners 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- its a life-time practice

27
The Echo
  • Definition A verbal reflection of internal
    thought processes
  • Method
  • Explain what you are doing
  • Filter what you dont 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
  • Youre 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
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