The case for hospice care in long-term care environments.

Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.

Adult education program in palliative care for nursing facility physicians: design and pilot test.

Nursing facilities (NF) are important sites for the care of dying patients. Curricula likely to improve end-of-life care are needed for NF physicians. To this end, a model medical school palliative care curriculum was modified for experienced NF physicians. Adult learning techniques were emphasized, as well as interactions likely to change physician behavior. Inclusion of the opinion leader, audit with feedback, use of consensus guidelines, and other techniques for changing physician behavior were included. Written materials to supplement the course were identified. This new program was pilot tested and improved. An initial audit of physician practices and survey of the NF staff, a half-day adult educational session, and follow-up with the NF medical director is suggested. This intervention should be tested to determine if it improves patient end-of-life care outcomes in this setting.

Required training in hospice and palliative care at the University of Maryland School of Medicine.

BACKGROUND: Over a period of four years the authors developed and integrated into the curriculum of their medical school training programs in palliative medicine. Critical required elements in the freshman year focus on attitudes and the physician's role in the care of terminally ill patients and their families. A 16-hour module has been designed to be a required element for junior students. It includes in-depth classroom and experiential training in palliative medicine. The results of the pilot of this module are presented. METHODS: The module consisted of one four-hour half-day session for four consecutive weeks during the ambulatory block in internal medicine. The first half-day class included both lectures and small-group discussions. Pain management, management of non-pain symptoms, and recognition of and basic interventions in spiritual and psychosocial suffering were covered. Required out-of-classroom reading assignments were distributed. The second and third half days were experiential, during which the student, in the company of a hospice nurse, made palliative care evaluations of terminally ill hospice patients. The last half day was a classroom session where the students presented their palliative care plan(s) for the patient(s) they had encountered on half days 2 and 3 to an interdisciplinary team (IDT) of the other students, a hospice medical director, a social worker, a hospice nurse, and a chaplain. Student scores on a 60-item objective test and participation in the IDT meeting were the primary data sources used to evaluate student achievement of the course objectives. RESULTS AND CONCLUSIONS: The majority of students attained the course objectives. Student evaluations of the module were very positive, particularly with regard to the home visits and the need for this training. It is anticipated that the module will be required during the 1999-00 academic year, with each student's performance contributing to his or her final grade in junior medicine.

Incorporating education on palliative care into the long-term care setting. National Consensus Conference on Medical Education for Care Near the End of Life.

Approximately one-third of all Americans will pass through a long-term care facility before they die, and many who require palliative care will reside there during the final weeks and months of their lives. In order to address this need, the unique characteristics of long-term care facilities are outlined, and the incentives for all levels of academic institutions to offer education in that setting are presented.

Hospice care in the nursing home.

Hospice care is being used more frequently to provide skills and services that are not otherwise available in nursing homes. For eligible terminally ill patients, the Medicare Hospice Benefit supplies an interdisciplinary team with skills in pain management, symptom control and bereavement assistance. The Medicare Hospice Benefit also covers the cost of durable medical equipment and drugs, except for a nominal drug copayment fee. The services of the hospice team supplement the usual nursing home care at a time when staff, family members and the patient are facing the increased and urgent needs associated with the dying process. The Medicare Hospice Benefit can make it much easier for physicians and nursing home staff to provide comprehensive palliative care for terminally ill patients.

Hospice and palliative care education in medical school: a module on the role of the physician in end-of-life care.

BACKGROUND: As a part of a program to integrate comprehensive palliative care education at the University of Maryland School of Medicine, a new teaching module was incorporated into the Introduction to Clinical Practice course for freshman medical students. METHODS: The module is entitled "The Role and Responsibility of the Physician in Palliative and End-of-life Care: the Inter-disciplinary Team Approach." The teaching objectives are: 1) describe the value of palliative and end-of-life care as a professional practice; 2) delineate the barriers to physician competence in end-of-life care; 3) describe the concept of hospice and the multidisciplinary approach to the care of the terminally ill; 4) List the fundamental areas of knowledge and skills required for a physician to be an effective member of the palliative care team. The format of the module is a 30-minute didactic/interactive overview of the teaching objectives, followed by a 30-minute videotape "Care Beyond Cure," produced by the National Hospice Organization. The class then breaks up into small groups to discuss, over a two-hour period, a hypothetical illustrative case. RESULTS AND CONCLUSIONS: The module was applied to the freshman medical student class in the 1995-1996 academic year. All freshmen were required to take it. Outcome evaluation utilized tools to assess attitude and cognitive domains. The attitude survey revealed that the majority of the students agreed that care of the dying could be a rewarding experience for the physician (72%) and that the case had helped them to understand the physician's role (93%). Overall, 82% wanted to learn more about the subject. Cognitive assessment tools indicated that the students satisfactorily understood the fundamental definitions of palliative care and hospice.

Assessing medical care of dying residents in nursing homes.

Although approximately one of five people in the United States die in nursing homes (NHs), little has been written about their quality of dying, including the quality of terminal medical care. The purpose of this study is to review actual medical practices in NHs to suggest factors important for delivering good quality terminal care. Four NHs were surveyed for management of residents who died in 1992. A convenience sample of charts of newly admitted and longer term residents were abstracted for demographic variables, death, diagnostic categories, and various laboratory and other parameters. Charts of those residents who died were further reviewed using indicators of quality medical care, such as presence of advance directives, control of pain, and control of dyspnea, based upon recent published clinical practice guidelines for terminal care in NHs. Three hundred and seventy-one charts were abstracted. Forty-one charts documented the resident's death. We found that NHs without regulatory difficulties usually had expected deaths that were managed approximately as measured by terminal medical care quality indicators. NHs with a history of regulatory difficulties had a higher prevalence of residents who died suddenly and unexpectedly, often with problems in the quality of care as measured by the same indicators. There was a correspondence between physician certification, antemortem diagnosis of terminal illness, and appropriate terminal care. We conclude that physicians are able to recognize impending death and redirect the medical care of dying NH residents toward goals of terminal care management. This is more likely to occur in a NH environment that places greater emphasis upon total quality management. We suggest that another indicator in providing good NH terminal care is the physician's performance in predicting a short life expectancy.

Educational program in palliative and hospice care at the University of Maryland School of Medicine.

BACKGROUND: The objective of this enterprise was and is to develop a validatable educational program on palliative and hospice care with a multidisciplinary perspective for the University of Maryland School of Medicine. METHODS: An interdisciplinary education committee consisting of experts in palliative and hospice care and an expert in educational design and evaluation was established to develop the program. Program development, which is ongoing, includes a comprehensive instructional design phase, vertical integration of the program into the medical school curriculum, and outcome evaluation. RESULTS: The instructional design phase has been accomplished; hence, the focus of this paper is on this aspect of program development. In addition, some integration of specific content areas into the medical school curriculum has been implemented. CONCLUSIONS: When complete, the program will focus on developing skills and knowledge using a variety of interactive educational modalities, including problem-based learning, case study discussions, role playing, and practical experience at hospice and palliative care sites. Topics to be covered are symptom control, the compassionate approach to patient care, communication between physicians and patients or family members, professional collaboration on a multidisciplinary palliative care team, ethical and legal issues pertaining to end-of-life care, and the value of palliative medicine as a profession.

Indicators of quality medical care for the terminally ill in nursing homes.

PURPOSE: To identify medical care indicators for nursing home terminal care. DATA SOURCES: Studies examining care of terminally ill patients were identified using computer, bibliography, and expert searches; input from nursing home medical directors in Maryland; and input from expert geriatricians. STUDY SELECTION: More than 900 articles, books, and abstracts from meetings covering medical care for terminally ill patients were reviewed. Information from more than 100 publications is included. DATA EXTRACTION: Indicators of medical care for terminally ill patients, which can be used to quantify performance with respect to standards, guidelines, and options, were identified initially through review of the literature. DATA SYNTHESIS: Indicators were refined by input from medical directors of Maryland long-term care facilities and subsequent review by expert geriatricians. CONCLUSIONS: Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also described.

Review of medical care in cited nursing homes: key areas of deficiency.

This article identifies key areas of physician performance in nursing homes (NHs) cited by state regulators. Six faculty members of the University of Maryland Department of Family Medicine reviewed medical care in ten Maryland NHs, which constituted 6.7% of Maryland's Comprehensive-level beds, with a sample of 547 charts and 81 physicians. The reviewers recorded the absence of expected minimum standards of performance in patient care. Nine of the NHs had been cited and one was anticipating an audit by state regulators. Citation by regulators corresponded with inadequate documentation of patient history and physical examinations, especially of neurologic conditions; with inadequate health care maintenance; with mismanagement of laboratory findings such as bacteriuria; and with lack of medical administrative leadership and quality management. These key areas of physician performance should be regularly assessed or systematically changed in all NHs to maintain at least minimum standards of care.

Readers' responses ... medical noncompliance.

The Second Opinion staff invited a number of its readers who are physicians to respond to our recent Case Stories section on medical noncompliance, which included a case story by Kevin Coleman and commentary and overview by Arthur W. Frank (Second Opinion 17, no. 3 [January 1992]). Our thanks to those who shared their reflections, a number of which have been excerpted here.