OUTLINE FOR DESCRIPTION OF ROTATION

ROTATION: Palliative Care and End of Life Care

PRECEPTORS: Pat O’Malley, DO, Paul LeMarbre, MD, Jane Welloch, MD, Maureen Froemming and Angel’s Grace Hospice Staff

DURATION:            Four-week, half time, required rotation, to be combined with a required
Ophthalmology experience.

1.       GOALS/OBJECTIVES:

 Understand basic principles of palliative care and hospice.

 Understand the physician's role in hospice care; work effectively with the interdisciplinary hospice team including nursing, social work and clergy.

 Learn and demonstrate clinical skill in pain symptom management

 Learn and demonstrate clinical skill in managing other common end-of-life symptoms (nausea, vomiting, constipation, dyspnea and delerium).

 Learn and demonstrate clinical skill in how to determine prognosis.

 Demonstrate clinical skill in talking with patients about prognosis, bad news, hope, spiritual issues, ethical issues and legal issues.

 Demonstrate clinical skill in facilitating a family conference.

 Demonstrate knowledge of common legal, ethical & professional issues in palliative care.

 Develop values and attitudes that support effective work with patients at the end of life, as well as personal self-care and resiliency.

2.       EXPECTATIONS:

 Attend an orientation session with Maureen Froemming at hospice.

 Round on hospice patients with Dr. O’Malley on Tuesday and Friday mornings each week.

 Attend weekly multidisciplinary team meetings Friday morning at Angel’s Grace hospice.

 Participate in the initial nursing assessment for at least one hospice patient.

 Participate in the initial patient visit by the hospice social worker and chaplain.  

 Complete readings and other self-study assignments in a timely manner.

 Assist Dr. O’Malley in managing patient care issues

Optional:

 Round with Dr. O’Malley one weekend (Saturday/Sunday) during the rotation, and take Saturday call.

 Take call one week-night per week during the rotation.

3.       PREPARATIONS/TEXTS:

· Weissman, DE & Ambuel, BA. Improving end-of-life care: A resource guide for physician education. Medical College of Wisconsin, Milwaukee, WI, 1999.

· Wrede-Seaman, L. Symptom management algorithms, a handbook for palliative care. Intellicard, Yakima, WA, 1999.

· EPEC: Education of Physicians on End-of-life Care, Trainer's Guide on CD-ROM. American Medical Association.

· Rousseau, Paul.  Primary Care Clinics in Office Practice: Palliative Care, 28(2): June 2001.  W.B. Saunders Company, Philadelphia.

4.       TYPICAL WEEK:

 Participation in residency conferences.

 Participate in weekly Angel’s Grace Hospice interdisciplinary staffing.

 Round two times per week with Dr. O’Malley.

 Attend Angel’s Grace Hospice at least 2 half-days per week.

 Manage patient care issues as they arise.

 Participate in family meetings, home visits, and other events as needed. 

 Reading and self-study. 

 Literature review and library research to explore areas of interest.

5.       WORK-UP/WRITE-UPS:

 Complete

6.       PROCEDURES:

· Pain assessment and management methods.

· Assessing & managing other symptoms

· Determining functional status using ECOG and Karnofsky scales.

· Estimating prognosis.

· Teaching relaxation, guided imagery and meditation.

· Conducting a biopsychosocial history for hospice admission.

· Discussing bad news, prognosis and treatment planning.

· Moderating a family conference.

· Providing family support at the time of death and later.

7.       AVAILABLE EDUCATIONAL EXPERIENCES/CONFERENCES:

8.       IMPACT OF OFFICE SCHEDULE/NOON CONFERENCES/FAMILY PRACTICE MORNING ROUNDS:

 The resident will be able to attend most regular residency conferences, however, Dr. O’Malley rounds at Angel’s Grace Hospice in the early morning therefore residents may miss some regular residency conferences to round with Dr. O’Malley at least two mornings per week.

9. CALL AND SHARED CALL: 

 No call required.

 Call may be arranged with Dr. O’Malley and Angels Grace Hospice.

10. WEEKEND REQUIREMENTS:

 None.

11.     VACATION/TIME OFF:

 2 days vacation allowed for the block.

12.     STRENGTHS:

 An opportunity to learn skills in end-of-life care and refine advanced skills in patient communication.

 A very rewarding group of patients to work with.

13.     WEAKNESSES:

 End-of-life care is inherently unpredictable and will require some work evenings and weekends.

14.     OTHER:

15.     EVALUATION:

 The resident will meet with the preceptor at the beginning of the rotation to identify specific goals for the rotation. Informal discussions will occur throughout the rotation to review rotation goals.  At the end of the rotation Pat O’Malley and Maureen Froemming, will complete an evaluation form and the resident will complete a self-assessment.

Revised: 6/1/05 – BA:lmc

Appendices:  Palliative Care and End of Life Care Rotation

1. Documentation of educational experience.

2. Biopsychosocial hospice admission.

Reviewed: 6/1/05 – BA:lmc

Palliative Care Resident Education Documentation

(Complete after patient discharge or death and place in resident education file)

Patient ID number:_____________________________________             Date: _____/_____/_____

Date of initial assessment: _____/_____/_____   Date of  death/  discharge: _____/_____/_____

Activities complete (check all that apply):

_____ Completed initial biopsychosocial assessment

_____ Home visit(s) (number: _____)

_____ Home visit at time of death

_____Bereavement visit following death

_____ Moderated family conference

_____ Observed initial nursing assessment

_____ Observed social work assessment or visit

_____ Attended hospice staffing(s) (number: _____)

_____ Spiritual concerns

_____ Observed clergy visit

_____ Discussed patient's spiritual concerns

_____ Symptom management (check all that apply):

_____ Pain-medication

_____ Pain-Relaxation & imagery

_____ Delerium

_____ Nausea & Vomiting

_____ Constipation

How would the patient answer this question -"What are the most important contributions your doctor made to your care?"

How would the family answer this question -"What are the most important contributions the doctor made to your relative's care, and to the family?"

Consider your work with this patient including your knowledge base, technical skills and interpersonal behavior.  Identify areas of strength, or possible strength.  Give specific, behavioral examples of each strength.

Identify challenging areas where you wish to continue developing. Give a specific behavioral example of each.

Patient name :                                                                                      DOB:          /          /               ID#

Diagnoses:

Presenting problem(s):

Physical exam  performed?  YES  NO

SIGNS & symptoms:

Nausea/vomiting?   YES  NO

Constipation?    YES  NO

Pain Present?	YES     NO
Location:
Duration:
Temporal patterns:
Modifiers:
Quality:	somatic     visceral     neuropathic
Intensity (0 to 10):

Abbreviated Mini-Mental Examination  Age  Birth date  Recognizes 2 people (doctor, nurse, family members)  Hospital or clinic name, or knows location  Address for recall at end of test (e.g. "12 Main Street")  Present year  Current time to nearest hour  Current president  First president, or year WWII ended  Count backward from 20 to 1 Ask for address given as item 5 above	Mental Status Symptoms  Impaired memory  Impaired thinking & judgement  Reduced attention*  Perceptual disturbances*  Hallucinations*  Incoherent speech*  Altered sleep/wake cycle*
9-10 normal;  8 borderline;  0-7 Borderline	Starred items characteristic of delerium

Functional Performance  Status
ECOG	Karnofsky	Description
0	100	Normal; no symptoms
1	70-90	+ Symptoms; manages self care
2	50-60	In bed < 50%
3	30-40	In bed > 50%
4	10-20	In bed 100%
5	0	Dead

oTHER SIGNS OR Symptoms:

Family GEnogram & caregivers (Mark family caregivers with an *  and  list non-family caregivers.)

FAMILY &  CAREGIVER CONCERNS & NEEDS:

Patient's Understanding of medical condition & prognosis:

Patient's Concerns & fears:

Patient's Spiritual Concerns:

Patient's GOALS:

ASSESSMENT & PLAN:

PHYSICIAN SIGNATURE: ________________________________________             DATE: _____/_____/_____

Note Dictated?    YES  NO