A Statewide Survey to Understand Barriers to Utilization of the Medical Orders for Scope of Treatment Form among Emergency Medical Service Providers.

Background: Advance care planning allows communication of end-of-life goals. The Kentucky medical orders for scope of treatment (MOST) form became a legal medical order in 2015. The Kentucky MOST Coalition formed in 2017 to implement MOST. Objectives: In 2019, Kentucky MOST Coalition members developed a survey to determine emergency medical services (EMS) providers' understanding and barriers to utilization of MOST. Design: The Kentucky Board of EMS e-mailed the survey to its members. The survey was voluntarily completed by EMS providers. The data were analyzed by Kentucky MOST Coalition. Results: A majority of participants had never (72%) encountered a MOST form. In addition, 69% said they had never received MOST training. However, 60% knew that "the MOST form is a physician order and shall be followed in all settings." Conclusions: The majority of the EMS providers knew basic information about MOST. However, accessibility and education were barriers to utilization of MOST. EMS providers need continuing education. Education surrounding MOST can help to ensure a person-centered approach.

"Opening eyes to real interprofessional education": results of a national faculty development initiative focused on interprofessional education in oncology palliative care.

The purpose of this study was to evaluate participants' feedback related to their experience in the Interprofessional Education Exchange (iPEX) program, a training initiative for faculty development in interprofessional oncology palliative care education. Participants voluntarily submitted a written reflection using a guide. The research team used qualitative content template analysis techniques to determine codes and categories based on the reflections and selected representative quotations (meaning units) from the data. Fifty-three reflections (100%) submitted by those completing the training were included in the analysis. The most appreciated aspects of the training were the opportunity for exchange of ideas and programs and the time allowed during the workshop for each team to work on developing their unique plan for interprofessional education (IPE) in oncology palliative care at their home institution. The iPEX program proved to be feasible, well-accepted, and valued by participants who reported personal, professional, and team growth and expressed appreciation for program support, content, and the exchange of ideas in a face-to-face setting. The results demonstrate that a faculty development program built on recommendations in the literature contributed to successful efforts to plan and initiate IPE in oncology palliative care.

Pneumonia in older adults.

PURPOSE OF REVIEW: The purpose of this review is to address the relevant issues surrounding older adults with community-acquired pneumonia (CAP) today. RECENT FINDINGS: Approximately 1 million people >65 years have CAP in the US per year, which is more than previously reported (or realized). Older adults are vulnerable to the increasing prevalence of viral CAP, as the SARS-CoV-2 pandemic emphasizes, but pneumococcus is still the most common pathogen to cause CAP. Racial disparities continue to need to be addressed in order to improve early and late outcomes of older adults with CAP. SUMMARY: The epidemiology of CAP, specifically for older adults is changing. More recent pathogen incidence studies have included culture, as well as newer microbiological methods to determine etiology. Current disparities among disadvantaged populations, including African-Americans, result in more comorbidities which predisposes to more severe CAP. However, outcomes in the hospital between races tend to be similar, and outcomes between age groups tends to be worse for older compared to younger adults. Finally, the cost of CAP is significant compared to diabetes mellitus, myocardial infarction and stroke.

Medicine as It Should Be: Teaching Team and Teamwork during a Palliative Care Clerkship.

BACKGROUND: Interprofessional Education (IPE) is an important component of medical education. Rotations with palliative care interdisciplinary teams (IDTs) provide an optimal environment for IPE and teaching teamwork skills. OBJECTIVE: Our objective was to assess the learning of senior medical students during a palliative care rotation. DESIGN: A constant comparison method based on grounded theory was used in this qualitative study. SETTING/SUBJECTS: Senior medical students completed a semi-structured reflective writing exercise after a required one-week palliative care clerkship. Sixty randomly selected reflective writings were analyzed. MEASUREMENTS: The reflective writings were analyzed to evaluate the student's experiences. RESULTS: Dominant themes identified were related to teams and teamwork. Eight specific themes were identified: value of IDT for team members; value of IDT for patient/family; importance of each team member; reliance on other team members; roles of team members; how teams work; team communication; and interdisciplinary assessment and care planning. Students described exposure to novel experiences and planned to incorporate newly learned behaviors in their future practice. CONCLUSION: By participating in palliative care IDTs, medical students consistently learned about teamwork within healthcare. Additionally, they learned the importance of such teamwork to patients and the team itself. Rotations with palliative care IDTs have a significant role to play in IPE and preparing medical students to practice on teams.

Implementing Chief Resident Immersion Training (CRIT) in the Care of Older Adults: Overcoming Barriers and Promoting Facilitators.

The Chief Resident Immersion Training (CRIT) in the Care of Older Adults curriculum was developed at Boston University School of Medicine to improve the care of older adults through an educational intervention. The curriculum targeted chief residents (CRs) because their role as mediators between learners and faculty provides the greatest potential impact for transmitting knowledge. The goals of CRIT are to: (1) provide education on geriatric principles and on teaching/leadership skills, (2) foster interdisciplinary collaboration, and (3) complete an action project. This study demonstrates successful implementation of CRIT at a different academic institution in a rural state. The CRs indicated that their confidence in their ability to apply and teach geriatrics improved after CRIT. In addition, the CRs indicated that CRIT improved their confidence in their overall skills as CRs. The barriers and facilitators to implementation are addressed in order to promote successful adoption of CRIT at other institutions, including those in rural states.

Unlocking the closed door: arguments for open access hospice.

The traditional view of standard hospice (SH) care is that once begun, the doorway toward curative and other forms of nonpalliative treatment is irrevocably locked. We will argue that such a traditional view needs to be reassessed in light of new arguments and data regarding access to these avenues of treatment. We will argue that patients should be supported in their transition from SH to open access hospice (OAH). Open access hospice should be available to all patients because of ethical arguments, patient satisfaction arguments, and costs of care arguments. More randomized controlled research trials need to be performed to study the impact of OAH versus SH. This research should focus on patient satisfaction, cost, and survival.

A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life.

OBJECTIVES: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN: Nationwide telephone survey. SETTING: Five VA medical centers. PARTICIPANTS: Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS: The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items). RESULTS: Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS: The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Meeting American Council of Graduate Medical Education guidelines for a palliative medicine fellowship through diverse community partnerships.

BACKGROUND: The field of hospice and palliative medicine has grown to include more than 50 fellowship training programs. In 2007 hospice and palliative medicine received American Board of Medical Specialties (ABMS) recognition as a subspecialty of medicine. Palliative medicine fellowships will begin formal accreditation under the American Council of Graduate Medical Education (ACGME) in 2008. OBJECTIVE: This paper details how one academic institution complied with draft ACGME Program Requirements for Fellowship Education in Hospice and Palliative Medicine addressing training sites and experiences by utilizing innovative community partnerships. RESULTS: Through carefully designed collaborative partnerships with community organizations three draft ACGME requirements for accreditation were met. It is anticipated that the program will receive full accreditation through the ACGME in 2008.

Eliciting goals of care in a nursing home.

OBJECTIVES: To identify enablers and barriers facing providers and staff in initiating Goals of Care (GOC) discussions with patients in the nursing home. DESIGN: Qualitative methods, one-on-one interviews. The interviews began with eliciting the participant's definition of GOC. The open-ended questions were designed to assess recent experience and satisfaction with the participant's role in the GOC discussion. SETTING: Nursing home. PARTICIPANTS: We interviewed 23 nursing home staff and providers. MEASUREMENTS: Transcripts were qualitatively analyzed. RESULTS: Five themes emerged that were identified as barriers to discussing GOC: (1) Fear of legal ramifications; (2) Not enough education on how to have a GOC discussion; (3) Family not involved on a regular basis; (4) Time pressure; (5) Interdisciplinary team not involved. Five themes also emerged that were identified as enablers to the GOC discussion: (1) Education/experience with the GOC discussion; (2) Interdisciplinary team involved in the discussion; (3) Established trusting relationship with the patient/family/other staff; (4) Terminal diagnosis/hospice involvement; (5) Discussion occurs in-person. CONCLUSION: A major finding of these interviews is the lack of systematic attention to GOC in the nursing home setting. Since education and experience were identified as crucial to understanding GOC, more formal education and observed practice discussing GOC is needed for all staff. The outcomes of GOC discussions should be documented in the patient record and be accessible to all staff and communicated systematically to all staff. Addressing these barriers and facilitating these enablers to the GOC discussion will improve the care of nursing home patients.

Eliciting Goals of Care in a nursing home.

OBJECTIVES: To identify enablers and barriers facing providers and staff in initiating Goals of Care (GOC) discussions with patients in the nursing home. DESIGN: Qualitative methods, one-on-one interviews. The interviews began with eliciting the participant's definition of GOC. The open-ended questions were designed to assess recent experience and satisfaction with the participant's role in the GOC discussion. SETTING: Nursing home. PARTICIPANTS: We interviewed 23 nursing home staff and providers. MEASUREMENTS: Transcripts were qualitatively analyzed. RESULTS: Five themes emerged that were identified as barriers to discussing GOC: (1) Fear of legal ramifications; (2) Not enough education on how to have a GOC discussion; (3) Family not involved on a regular basis; (4) Time pressure; (5) Interdisciplinary team not involved. Five themes also emerged that were identified as enablers to the GOC discussion: (1) Education/experience with the GOC discussion; (2) Interdisciplinary team involved in the discussion; (3) Established trusting relationship with the patient/family/other staff; (4) Terminal diagnosis/hospice involvement; (5) Discussion occurs in-person. CONCLUSION: A major finding of these interviews is the lack of systematic attention to GOC in the nursing home setting. Since education and experience were identified as crucial to understanding GOC, more formal education and observed practice discussing GOC is needed for all staff. The outcomes of GOC discussions should be documented in the patient record and be accessible to all staff and communicated systematically to all staff. Addressing these barriers and facilitating these enablers to the GOC discussion will improve the care of nursing home patients.

Evaluation of an educational intervention to encourage advance directive discussions between medicine residents and patients.

INTRODUCTION: Most medical schools are remiss in preparing physicians in end-of-life communication skills. As a result, many residents are uncomfortable with approaching the patient, have not developed the skills required to discuss the patients' wishes, and avoid end-of-life conversations. OBJECTIVE: To evaluate an educational intervention focused on teaching residents skills to discuss advance directives. METHODS: Medicine Residents attended a morning report consisting of both didactic training and participation in a role-play exercise. Charts of inpatients were audited ten days prior to and five days subsequent to the intervention to ascertain if there was a documented do-not-resuscitate (DNR) discussion. RESULTS: Seventy-nine records of patients assigned to eight physicians who attended the intervention and who were responsible for patients before and after the intervention were reviewed. Of the patients assigned to these residents before the intervention, 32% had a documented DNR discussion. Thirty-four (34%) of the physicians had discussions after the intervention, demonstrating only minimal improvement. CONCLUSIONS: A single intervention may be inadequate to affect physician practices related to DNR discussions. Physicians may need more interactive, experiential learning opportunities and related supervision over the course of their training in order to improve these communication skills. A chart review that only records if a DNR discussion was documented in the medical record may not be the best tool to evaluate the success of this educational intervention. Improvement in attitudes and knowledge were not able to be measured.

Pneumonia in older residents of long-term care facilities.

Compared with community-dwelling persons, residents in long-term care facilities have more functional disabilities and underlying medical illnesses and are at increased risk of acquiring infectious diseases. Pneumonia is the leading cause of morbidity and mortality in this group. Risk factors include unwitnessed aspiration, sedative medication, and comorbidity. Recognition may be delayed because, in this population, pneumonia often presents without fever, cough, or dyspnea. Accurate identification of the etiologic agent is hampered because most patients cannot produce a suitable sputum specimen. It is difficult to distinguish colonization from infection. Colonization by Staphylococcus aureus and gram-negative organisms can result from aspiration of oral or gastric contents, which could lead to pneumonia. Aspiration of gastric contents also can produce aspiration pneumonitis. This condition is not infectious initially and may resolve without antibiotics. Antibiotics for the treatment of pneumonia should cover Streptococcus pneumoniae, Haemophilus influenzae, gram-negative rods, and S. aureus. Acceptable choices include quinolones or an extended-spectrum beta-lactam plus a macrolide. Treatment should last 10 to 14 days. Pneumonia is associated with significant mortality for up to two years. Dementia is related independently to the death rate within the first week after pneumonia, regardless of treatment. Prevention strategies include vaccination against S. pneumoniae and influenza on admission to the care facility. This article focuses on recent recommendations for the recognition of respiratory symptoms and criteria for the designation of probable pneumonia, and provides a guide to hospitalization, antibiotic use, and prevention.