HMC Inpatient Palliative Care Consultation Rotation Learning Goals and Objectives
OVERVIEW
During this rotation, under the supervision of the palliative care team, interns and residents will provide inpatient palliative care consultation services
to patients and families facing serious illness that will include:
--Complex symptom management (pain, nausea/vomiting, constipation, anxiety, dyspnea etc.)
--Understanding personal stories and how they relate to healthcare preferences and decision making
--Cultivating prognostic awareness
--Discussions regarding goals of care, resuscitation preferences and advance care planning
--Religious/spiritual/cultural preferences and practices around serious illness and death
--Assessment of decisional capacity
--Emotional, psychological and bereavement support
--Care of the imminently dying patient, including wishes for care before, after and at the time of death
--Discharge planning, including long term care, outpatient palliative care, hospice eligibility and hospice referrals
OBSERVATION AND FEEDBACK
Communication is best learned through deliberate practice and this rotation provides unique opportunities for direct observation and feedback from
supervising providers and your fellow trainees. All feedback should be timely, constructive and focused on key behaviors and skills. In general, if you
are leading a visit, your supervising provider will do the following:
1. Set a Learning Goal: Before the encounter, they will help you identify the learning opportunity, outline a specific learning goal, and help frame
the skill challenge associated with that goal (for example, identifying and responding to emotion).
2. Observe: Using active observation and real-time tracking they will collect data on the encounter. All trainees who are not leading the encounter
will also write down their observations of the encounter. The supervising provider will also be there to guide the conversation when you are
stuck.
3. Debrief: After the encounter, the group will briefly review the visit, focusing on the learning goal you identified and ask the following questions:
a. What did you do well?
b. Anything you would do differently next time?
c. What is one thing you learned from this encounter that you want to use again?
d. What do you want to work on during the next encounter?
PALLITIVE CARE GOAL COMPETENCIES BY LEVEL OF TRAINING IN THE 5 CORE AREAS OF PALLITIVE CARE*
Adaptive approach to full range of emotions
COMMUNICATION
Effective approach to strong emotion
Basic approach to emotion
Emotion
Patient-Centered Communication
Patient and Family’s Perspective
Learner
Demonstrate patient-centered
communication (serious news,
resuscitation preferences)
Explore patient and family
perspective on illness (concerns,
values, preferences, goals)
Student
PAIN AND SYMPTOM MANAGEMENT
Non-Pain Symptoms
Anxiety, Depression, Delirium
Assess and provide differential
diagnosis, initial workup and
treatment for non-pain symptoms
Describe approach to diagnose
anxiety, depression, delirium
Describe key principles of opioids
Opioids
Pain
Learner
PALLIATIVE CARE PRINCIPLES AND
PRACTICE
Assess pain, distinguish nociceptive
from neuropathic
Student
Effective patient-centered
communication (prognosis, dying
process)
Explore patient and family
perspective and align plan of care
accordingly
Adaptive patient-centered communication
(uncertainty)
Adapt plan of care to complex, competing and shifting
priorities
Resident
Fellow
Assess and manage common nonpain symptoms
Use validated tools, employ a range of treatments,
utilize the IDT, and manage toxicity for non-pain
symptoms
Treat pain using opioids, non-opioids
and non-pharmacologic interventions
Use validated tools, employ a range of treatments,
utilize the IDT, and manage toxicity for anxiety,
depression, delirium
In depth knowledge of opioids, toxicity, use in
substance abuse, legal and regulatory concerns
Use validated tools, understand “whole pain”, employ
a range of treatments, utilize the IDT and manage
toxicity for pain
Resident
Fellow
Assess, diagnose and provide initial
treatment for anxiety, depression
delirium, make appropriate referrals
Apply key principles of opioids
Lead the IDT
Collaborate with members of the IDT
Describe the roles of the IDT
Interdisciplinary Team
Prognostication
Describe disease trajectory for
common illnesses
Palliative Care and Hospice
Continuum
Self-Care and Resiliency
Learner
Define palliative care and hospice
continuum
Reflect on personal experience of
death and dying
Student
Estimate prognosis using evidence
and knowledge for common illnesses
Explain the palliative care and
hospice continuum, make
appropriate referrals
Model self-reflection, acknowledge
team distress
Resident
Estimate prognosis using multiple sources for
common illnesses and some uncommon illnesses
Educate patient, families and other providers about
the palliative care and hospice continuum, follow
patients across transitions
Model self-care, lead team reflection, provide team
and staff support
Fellow
PSYCHOSOCIAL, SPIRITUAL AND
CULTURAL ASPECTS OF CARE
Identify spiritual distress
Spiritual Distress
Provide initial support for spiritual
distress, make appropriate referrals
Integrate cultural concerns into the
plan of care
Identify cultural concerns
Cultural Values, Beliefs and Practices
Identify psychosocial distress
Psychosocial Distress
Learner
Student
TERMINAL CARE AND BEREAVEMENT
Grief and Bereavement
Tasks of Death
Signs and Symptoms of Dying
Ethics
Learner
Describe normal grief and risk factors
for prolonged grief
Describe tasks of death
(pronouncement, family notification,
autopsy)
Identify common signs and symptoms
of imminent death and describe
initial treatment
Describe principles of withdrawing or
withholding life sustaining treatment
and rationale for obtaining a
surrogate
Student
Provide initial support for
psychosocial distress, make
appropriate referrals
Resident
Differentiate between normal grief
and prolonged grief, make
appropriate referrals
Perform tasks of death
Manage common signs and
symptoms of imminent death
Apply principles of withdrawing and
withholding life sustaining treatment,
evaluate decisional capacity, describe
principles of physician assisted death
Resident
Screen for, and provide initial counseling for spiritual
distress, utilize the IDT
Anticipate and advocate for cultural concerns,
connect patients and families to community resources
Screen and provide initial counseling for psychosocial
distress, utilize the IDT
Fellow
Assess and manage normal and prolonged grief
utilizing the IDT, community resources and referrals
when appropriate
Support and counsel family through tasks of death,
utilize the IDT
Manage complex signs and symptoms of imminent
death including terminal delirium, refractory pain and
use of palliative sedation
Understand and apply principles of palliative
sedation, futility, use validated tools for decisional
capacity, counsel patients requesting physician
assisted death
Fellow
*These competencies are adapted from work by Kristen Schaefer and colleagues, published in Academic Medicine.[1] Schaefer et al. identified five content areas for
palliative care: (1) Communication (2) Pain and Symptom Management (3) Palliative Care Principles and Practice (4) Psychosocial, Spiritual and Cultural Aspects of
Care and (5) Terminal Care and Bereavement. Within these five content areas, they identified 18 different developmentally appropriate competencies and surveyed
a national sample of palliative care education experts to rank the importance of these for medical students and residents. Though their project targeted physicians
(medical students and residents), the vast majority of these competencies are relevant across disciplines. Additionally, we added the last column, for healthcare
professionals specializing in palliative care, as an extension of these competencies and integrating the American Academy for Hospice and Palliative Medicine
(AAHPM) fellowship competencies [2] and the quality standards introduced by the National Consensus Project for Quality Palliative Care [3].
CAPC MODULES
https://www.capc.org/accounts/register/
https://www.capc.org/accounts/login/?next=/capc-central/login/
CAPC (Center to Advance Palliative Care) is an incredible national organization dedicated to increasing the availability of quality palliative care services
for people facing serious illness. It provides tools, training and technical assistance necessary to start and sustain successful palliative care
programs. This site if full of information, resources and updates on current events in palliative medicine. UW is a member and all employees of UW
have access to their online resources. To register all you need is your UW email (go to the “register” link above) and then login to CAPC central where
you can click on the CME/CE courses for pain management and communication. We recommend you complete these modules throughout your
rotation.
http://www.vitaltalk.org/
VitalTalk is a national non-profit started by our very own Anthony Back, MD, co-director of the palliative care center of excellence and his colleagues
from across the country. Originally starting as OncoTalk, it was developed to help train oncologist better communication skills and has great expanded
in to many other areas of medicine. There are great resources both for providers but also for educators. Under the providers tab, we recommend
watching the family conference video for this rotation: http://www.vitaltalk.org/clinicians/family.
REFERENCES
[1] Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, Sanchez-Reilly S, Block SD. Raising the bar for the care of
seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med.
2014 Jul;89(7):1024-31.
[2] American Board of Hospice and Palliative Medicine (ABHPM) Competencies Workgroup. Hospice and Palliative Medicine Core Competencies,
Version 2.3. http://aahpm.org/uploads/education/competencies/Competencies%20v.%202.3.pdf. Accessed December 1, 2014.
[3] Ferrell B, Connor SR, Cordes A, et al; National Consensus Project for Quality Palliative Care Task Force Members. The national agenda for quality
palliative care: The National Consensus Project and the National Quality Forum. J Pain Symptom Manage. 2007;33:737–744. 29 National Consensus
Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. 2013. http://www.nationalconsensusproject.org.
Accessed December 1, 2014.