Dying in America Improving Quality and Honoring Individual Preferences Near the End of Life (2015) / Chapter Skim
Currently Skimming:
4 Professional Education and Development
4 Professional Education and Development
Pages 221-262
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 221... ...
Removing these impediments would enhance basic palliative care as provided by clinicians who are not hospice and palliative medicine specialists. Next, the chapter describes the roles and preparation of palliative care team members, including specialists in palliative care in the professions of medicine, nursing, social work, pharmacy, and chaplaincy; rehabilitation therapists and direct care workers are also discussed.
|
From page 222... ...
Nearly 100 hospice and palliative medicine fellowship programs, with the capacity to graduate some 200 fellows annually, have gained accreditation. Similar gains have occurred in nursing and social work.
|
From page 223... ...
Moreover, the number of active organizations dedicated to the advancement of palliative care, partly through the setting or promotion of standards, has grown and now includes the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the National Hospice and Palliative Care Organization (formerly the National Hospice Organization) , the Hospice and Palliative Nurses Association, and the Social Work Hospice and Palliative Care Network.
|
From page 224... ...
. Basic palliative care is vital because hospice and palliative medicine specialists will never be sufficient in number to provide regular face-to-face treatment of every person with an advanced serious illness.
|
From page 225... ...
Box 4-1 summarizes these domains. IMPEDIMENTS TO CHANGING THE CULTURE OF CARE THROUGH EDUCATION Health professions education can help transform the care of people with advanced serious illnesses.
|
From page 226... ...
However, the Liaison Committee's requirement is vague -- it does not specifically mention palliative care, for example -- and it does not appear to be rigorously enforced through specific standards or clear expectations. Perhaps partly as a consequence, end-of-life care, including principles and practices of palliative care and hospice and palliative medicine, still is not taught widely and intensively in U.S.
|
From page 227... ...
. Other examples of how hospice and palliative medicine content has been incorporated into medical school curricula include • George Washington University's standardized patient case on pal liative care in the second year, coupled with a course on medical interviewing and decision making; • the University of Rochester's content on advance care planning, chronic pain management, and discussion of treatment goals pro vided in the first and second years, supplemented by a session on palliative care in a 2-week follow-up to a clinical rotation in the third year (Shaw, 2012)
|
From page 228... ...
These structures also fail to facilitate interprofessional training. What appears to be needed is a core of board-certified hospice and palliative medicine specialists serving in appropriate departments or divisions as educators of medical students and residents and as liaisons with colleagues in other professions, especially nursing, social work, and chaplaincy.
|
From page 229... ...
. Continuing Medical Education Because many or most physicians have had little exposure to hospice and palliative medicine in their undergraduate and graduate education, efforts have been made to fill the gap through continuing medical education.
|
From page 230... ...
At Children's Hospital Boston, physicians participated with nurses, social workers, psychologists, and chaplains involved in pediatric critical care in a day-long interprofessional communication program (the Program to Enhance Relational and Communication Skills, or PERCS)
|
From page 231... ...
Historically, the lack of emphasis on palliative care seen in medical education appears to have been duplicated in nursing education. For example, registered nurse anesthetists received little training in palliative or end-of-life care as students, and a literature search involving preparation of certified registered nurse anesthetists found "no publications addressing the importance of incorporating elements of palliative care into nursing and nurse anesthesia practice" (Callahan et al., 2011, p.
|
From page 232... ...
. A major textbook in palliative nursing is divided into general principles, symptom assessment and management, the meaning of hope in the dying, spiritual care, special patient populations, end-of-life care across settings, pediatric palliative care, special issues for the nurse in end-of-life care, international models of palliative care, and a conclusion on a good death (Ferrell and Coyle, 2010)
|
From page 233... ...
Health professionals involved in either basic or specialty palliative care must respond in timely and appropriate ways when advanced disease trajectories take an unexpected path. Hospice and palliative medicine's focus on maximizing patient comfort and quality of life requires a different mind-set on the part of the care team, and often, considerable creativity.
|
From page 234... ...
According to a Macy Foundation report, for example, "medical education inculcates physicians with a ‘captain of the ship' attitude[,] which can impair interprofessional collaboration" (Josiah Macy Jr.
|
From page 235... ...
This section likewise focuses on the development of physician communication skills, but the committee believes that the development of these skills also is important for nurses and other health professionals. Effective physician communication in end-of-life situations has been described as follows: good communication in palliative medicine adopts a modern, patient centered, biopsychosocial-spiritual framework, and focuses on eliciting patient concerns, identifying their agenda, providing complete informa tion, but doing so in a way that allows patients and families to digest what they hear.
|
From page 236... ...
. • Instruction sessions on communication for first- and second-year medical students at the Warren Alpert Medical School of Brown University were rated highly by students for their effectiveness in enhancing communication skills and helping students gain perspec tive on and appreciate the complexities of health care situations (Shield et al., 2011)
|
From page 237... ...
ROLES AND PREPARATION OF PALLIATIVE CARE TEAM MEMBERS Palliative care team members include physician specialists in hospice and palliative medicine, palliative nursing specialists, hospice and pallia
|
From page 238... ...
This role, although it differs somewhat from setting to setting, is comparable to that of the hospice medical director, who, under the Medicare Hospice Benefit, "has responsibility for the medical component of the hospice's patient care program."13 Because of their relatively low numbers, hospice and palliative medicine specialists typically function as consultants rather than as direct care providers. Despite this predominantly consultative role, it appears reasonable, in the committee's view, for patients who are referred to specialty palliative care services to expect to be seen by a qualified palliative care physician at some point, similar to the expectation when a patient enrolls in hospice.
|
From page 239... ...
ABMS sponsors the hospice and palliative medicine certification examination with the participation of 10 certification boards. As Table 4-1 shows, two boards -- the American Board of Internal Medicine and American Board of Family Medicine -- account for 88 percent of all certifications among a total complement of about 6,400 hospice and palliative medicine specialists.
|
From page 240... ...
Taken together, however, data from Table 4-1 and the osteopathic certification process suggest a total of more than 6,500 board-certified hospice and palliative medicine specialists in the United States. This figure amounts to about 0.8 percent of all practicing U.S.
|
From page 241... ...
Nurses with the most training are the advanced certified hospice and palliative nurses -- nurse practitioners or clinical nurse specialists who deliver care similar to that delivered by physician specialists in hospice and palliative medicine. However, state scope-of-practice laws and regulations may impose some restrictions on practice for these nurses, such as a requirement that advanced practice nurses have formal physician backup protocols or strict limits on nurses' prescribing authority.
|
From page 242... ...
. Reflecting growth in the specialty, the Hospice and Palliative Nurses Association now claims 11,000 members, primarily hospice and palliative nurses, such as certified hospice and palliative nurses.
|
From page 243... ...
In recent years, the profession of social work has developed standards, certifications, and advanced levels of training for those providing support to people approaching death: • Since 2008, the National Association of Social Workers (NASW) has offered specialty certification in hospice and palliative care at the level of advanced certified hospice and palliative care social worker for licensed social workers who hold a master's degree in social work, have at least 2 years' experience in hospice and pallia tive care, and have acquired at least 20 hours of related continuing education.
|
From page 244... ...
. In a survey of 1,169 hospice and palliative care social workers, most reported being engaged in communicating the psychosocial needs of patients and families to other members of the care team and in assessing patients' and family members' grief and bereavement needs; few held NASW certification (Weisenfluh and Csikai, 2013)
|
From page 245... ...
. Given that symptom management for people who have advanced serious illnesses or are nearing the end of life relies heavily on the use of medications, pharmacists can play a key role in the interdisciplinary palliative care team.
|
From page 246... ...
offers certification in eight specialties, as well as two areas that provide an Added Qualification credential. As recently as 2011, BPS considered adding pain and palliative medicine as a specialty, but it has yet to do so (BPS, 2011)
|
From page 247... ...
. In a nationwide study of hospital patients who died between 2001 and 2005, the presence of chaplaincy services was associated with a 4 percent lower rate of hospital mortality and a 6 percent higher rate of hospice enrollment, after controlling for geographic variables, hospital type and size, population density, socioeconomic status, and presence of a palliative care program (Flannelly et al., 2012)
|
From page 248... ...
The category of direct care workers consists of nursing assistants, home health aides, and personal care aides. Direct care is not established as a profession, and workers often are foreign born (23 percent in 2010)
|
From page 249... ...
. Many direct care workers are employed by nursing homes, hospices, home health agencies, or continuing care residential communities, and others are hired by families and paid out of pocket for services provided in the home.
|
From page 250... ...
. Palliative Care Content in Medical Licensure and Certification Examinations Palliative care content in medical licensure and non–hospice and palliative medicine certification examinations appears limited.
|
From page 251... ...
. Conclusions The major improvement in the education of health professionals who provide care to people nearing the end of life has been the establishment of the specialty of hospice and palliative medicine, along with the establishment or growth of palliative care specialties in nursing and social work.
|
From page 252... ...
Specifically, • all clinicians across disciplines and specialties who care for people with advanced serious illness should be competent in basic pal liative care, including communication skills, interprofessional col laboration, and symptom management; • educational institutions and professional societies should provide training in palliative care domains throughout the professional's career; • accrediting organizations, such as the Accreditation Council for Graduate Medical Education, should require palliative care educa tion and clinical experience in programs for all specialties respon sible for managing advanced serious illness (including primary care clinicians) ; • certifying bodies, such as the medical, nursing, and social work specialty boards, and health systems should require knowledge, skills, and competency in palliative care; • state regulatory agencies should include education and training in palliative care in licensure requirements for physicians, nurses, chaplains, social workers, and others who provide health care to those nearing the end of life; • entities that certify specialty-level health care providers should create pathways to certification that increase the number of health
|
From page 253... ...
. ACGME (Accreditation Council for Graduate Medical Education)
|
From page 254... ...
medical schools: A systematic literature review. Journal of Palliative Medicine 10(1)
|
From page 255... ...
Palliative Medicine 27(3)
|
From page 256... ...
pharmacy schools. American Journal of Hospice and Palliative Medicine 30(6)
|
From page 257... ...
2009. Oxford textbook of palliative medicine.
|
From page 258... ...
. Lupu, D., and American Academy of Hospice and Palliative Medicine Workforce Task Force.
|
From page 259... ...
Journal of Palliative Medicine 7(5)
|
From page 260... ...
2012. Hospice and palliative medicine: Curriculum eval uation and learner assessment in medical education.
|
From page 261... ...
2012. Development and evaluation of a palliative medicine curriculum for third-year medical students.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.