A Strategy for Incorporating Palliative Care and End ...

A Strategy for Incorporating Palliative Care and End-of-Life Instruction into Physician Assistant Education Lisa C. Lanning, MS, PA-C; Bonnie A. Dadig, EdD, PA-C, Medical College of Georgia

BRIEF REPORT Feature Editor’s Note: With an aging population, there is a growing need for the nation’s health care providers to have an understanding of endof-life issues. This brief report describes

Purpose: Physician assistant (PA) education has not historically taught end-of-life and pal-

how a PA program incorporated instruction

liative care in its curricula. While medical education has been reformed in the past 15

about palliative care and end-of-life issues

years to include palliative care, PA education lags behind. The Medical College of Georgia

into the existing curriculum — a require-

PA Program obtained a HRSA grant in 2009 to teach PA students about end-of-life issues

ment of the Fourth Edition of the Standards

and improve palliative education in the didactic and clinical years. Educational Strategies:

— and the instructional results. The pro-

Sparse published data exist for end-of-life/palliative education in PA programs. We built a

gram found that students had a better

Wiki Internet tool to help teach these concepts. We revised objectives in clinical medicine,

understanding of end-of-life issues and

emergency medicine, and surgery to improve instruction in end-of-life issues, including

learned from each other by sharing their

common symptom management. We extended the adult medicine clinical course from 4

experiences through a Wiki Discussion

weeks to 8 weeks to provide long-term care and hospice exposure. Students journaled

Forum and that students reported the most

their adult medicine experiences on the Palliative Care Wiki Discussion Forum. Student

valuable settings for learning were hospice

Experiences: Students who participated in the Wiki Discussion Forum reported better

home visits, bedside instruction, and small

understanding of end-of-life issues for patients who were near death or actively dying.

groups. The experience also highlights the

Students expressed that bedside instruction, small groups, and hospice home visits were

effectiveness of interprofessional courses

valuable venues for learning about end-of-life care. Students recommended more frequent

to teach palliative and hospice care. As

and specific instruction in pain management and requested more time in hospice and criti-

other PA programs look for effective ways

cal care. Students appreciated learning from other students’ experiences through the Wiki

to meet the Standards, this article points

Discussion Forum. Conclusions: PA programs should incorporate palliative care and end-

the way to provide learning opportunities

of-life instruction into existing curricula. Pain management and treatment of common end-

that prepare students to face this growing

of-life symptoms should be emphasized. Structured clinical experiences in critical care,

health care need.

hospice, and long-term-care settings should be offered.

— David Asprey, PhD, PA-C Lisa C. Lanning can be reached at [email protected].

INTRODUCTION The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) published its Accreditation Standards for Physician Assistant Education, Fourth Edition, in March 2010.1 New and existing physician assistant (PA) programs will be required to meet new standards for palliative care and end-of-life education by September 1, 2010, as detailed below: B2.06 The program curriculum must include instruction in the provision of clinical medical care across the life span.

The Journal of Physician Assistant Education | 2010 Vol 21 No 4

ANNOTATION: Preclinical instruction prepares PAs to provide preventive, emergent, acute, chronic, rehabilitative, palliative and end-of-life care. It includes content relevant to prenatal, infant, children, adolescent, adult and elderly populations.1

A review of the Standards reminds us of the obligation that programs have to incorporate end-of-life curricula. However, for many programs the question is not what to add, but how do we add these additional requirements to the already burdensome PA curricula?

The Abstracts and Brief Reports section publishes short, focused communications on a research endeavor relevant to PA education or behavior. Submissions should be limited to approximately 1,500 words and one or two exhibits (tables or illustrations). The intent of this feature is to promulgate new information and provide a platform for additional research. Submissions (with a copy to journal staff at jpae@ PAEAonline.org) should be sent to: David Asprey, PhD, PA-C University of Iowa Email: [email protected] 41

A Strategy for Incorporating Palliative Care and End-of-Life Instruction into Physician Assistant Education

Medical education recognized a serious deficiency in end-of-life education in the mid-1990s and, in fact, some in PA education have been pushing for better and more structured end-of-life education for PAs. Berge, Prerost, and Foltz conducted a small study in 2001 of 300 PAs in Illinois to determine their attitudes toward hospice and assisted suicide.2 They found that 65% of PAs surveyed felt they received inadequate education in palliative care, and less than 15% of those believed their training was adequate to meet their practice needs, leading to an underutilization of hospice services. They also found a positive correlation between enhanced palliative care/hospice education and referral to hospice services.2 In 1997, the American Academy of Physician Assistants (AAPA) adopted a formal policy on End-of-Life Decision Making (reaffirmed 2004, amended 2009) that addresses the roles and responsibilities of PAs in end-of-life care.3 AAPA states that “Physician assistants and other providers who care for dying patients must be knowledgeable in managing that care…[they] should have specific and appropriate training in pain management and in the counseling of dying patients and their families.” The AAPA also recommends that PAs should discuss with their supervising physicians how to manage end-of-life issues, especially since PAs are dependent providers and “have a legal and ethical responsibility to the supervising physician, as well as to the patient.” Furthermore, PAs should be prepared to discuss “seriously and respectfully” all end-of-life issues with patients and families, including requests for assisted suicide, which the AAPA clearly states it does not advocate.3

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What to Teach and Where to Teach It? Ury, Reznich, and Weber conducted a needs assessment in 2000 to determine what specific palliative care skills are necessary for internal medicine residents.4 They compiled a list of nine important tasks: the top three were pain management, giving bad news, and advance directives. The remaining six were as follows: caring for family, nutritional support, when to withdraw care, ethical issues, management of common symptoms, and how to define palliative care. Inpatient rotations including geriatrics, ICU, and oncology were deemed to be the most useful venues for teaching about end-of-life issues. Small group settings and bedside instruction were felt to be more useful than grand rounds and lecture for all topics except for pain management.4 Casebased instruction using real patient scenarios was felt to be the most valuable, and rotation on a palliative care service, if available, was considered important.4 Inpatient experience was deemed very useful as “this is where death is visible and tangible.”4 Opacic and Petersen presented a poster at the Association of Physician Assistant Programs’ (now Physician Assistant Education Association) 2005 Education Forum detailing their pilot project to assess PA students’ knowledge of palliative care issues.5 Their findings were remarkably similar to Ury’s and Sullivan’s6: Knowledge of legal and ethical issues (advance directives, power of attorney, and family communication) were important, as were pain and symptom management. These symptoms included anorexia, agitation, constipation, delirium, dementia, depression, diarrhea, nutrition, and vomiting. Other important topics included addressing the PA’s own unwarranted fears of opiate addiction (a nonissue at the end of life) and recognizing

effective pain control.5 Table 1 illustrates the most important topics to include in palliative care education for PA students. Table 2 summarizes important symptom management at the end of life. The Medical College of Georgia (MCG) Curriculum Map (see Figure 1) demonstrates various places in our curriculum where students receive palliative care and endof-life instruction. EDUCATIONAL STRATEGIES

The Medical College of Georgia Experience The PA program at MCG, established in 1972, has a long tradition of grant-supported PA educational projects. The current grant cycle includes a US Health Resources and Services Administration (HRSA) grant to integrate palliative care education into the PA program. Our goal was to integrate palliative care educational issues into our PA program, improve patient-centered care, and improve quality of life for adults and children with progressively serious and life-threatening illnesses. Strategies identified to accomplish this were: 1. Adapt current objectives in clinical medicine, emergency medicine, and surgery courses, focusing on the patient and family perspective of the total impact of illness and medical interventions 2. Train PA students to work with palliative care providers 3. Teach PA students diagnosis, prognosis, and expected clinical needs for the remainder of the life of the patient 4. Establish clinical rotations in hospice and palliative care settings 5. Assist students in developing care 2010 Vol 21 No 4 | The Journal of Physician Assistant Education


Table 1. Essential End-of-Life Skills

plans with patients and families that optimize quality of life and relief of suffering

Cognitive Skills

Knowledge

Professional/Clinical Skills

Address spiritual and cultural issues at end of lifea

Pain managementa,b,d

Delivering bad newsd

6. Require students to journal their palliative care learning experiences

Manage own feelings about death and dyingb

Effective symptom managemente

Discuss advance directives with patients and familiesa,c,d,e

7. Provide additional palliative care instruction to PA students and graduates through CME offerings

Recognize potential biasesa,c

Recognize effective pain controla,e

Family communicationa,c,d,e

Ethical issues at end of lifea,d

Understand the dying processa

Address patient and family sufferingd

Understand palliative careb

Recognize the actively dying patienta

Emphasize aggressive use of comfort measuresa

8. Increase the 4-week adult medicine rotation to 8 weeks in the clinical year to expand palliative care, end-of-life, and long-term care clinical opportunities

Nutritional supportd Know when withdrawal of care is appropriated State laws and practice setting rules affecting PA practice in hospice and palliative care settingsb,c Know how to respond to patient and family requests for assisted suicidea,c Sources: a) Sullivan, Lakoma & Block 2003, b) Brown DH. Knowledge of Hospice and Palliative Care in Physician Assistants [Master’s Thesis]. Winchester, VA: Shenandoah University; 2007, c) AAPA, d) Ury et al 2000, e) Opacic & Petersen 2005

Table 2. End-of-Life Symptom Management Symptom Management

Pain Management

Delirium

Unwarranted fears of addiction

Dementia

Opioid and benzodiazepine tolerance

Anorexia

Recognize effective pain control

Vomiting Agitation Nutrition Constipation Diarrhea Depression Source: Opacic and Peterson 2005


A literature review revealed a paucity of published PA literature on end-of-life topics, hospice, or palliative care; consequently, we expanded our search to include the medicine and nursing literature. We also obtained information from a conference at the Veterans Administration Hospital (Augusta, Georgia) by Amos Bailey, MD, who detailed the new Comfort Care Orders to be initiated at several VA hospitals and inpatient hospice settings throughout the Southeast.7 From the literature and this conference, we identified several key topics to include in a 45-minute lecture. In order to have a centralized place for our students to access the identified resources, an organizational template using a Wiki website — at http://www.wetpaint.com/ — was created. The website, Palliative Care Resources for Physician Assistants, is free to educators and may be viewed at http://palliativecareforpas.wet paint.com/. The Wiki site houses articles in Adobe and Microsoft Word formats, videos on hospice and endof-life issues, and links to many Internet resources. The Palliative Care Wiki site was introduced to students, faculty, and alumni on April 24, 2009. In 43

A Strategy for Incorporating Palliative Care and End-of-Life Instruction into Physician Assistant Education Figure 1. Medical College of Georgia — Palliative Care Didactic Curriculum Map

August, the first cohort of the class of 2010 students was contacted by email to reintroduce the Wiki site as they began their 8-week adult medicine rotations. The students were directed to the Wiki Discussion Forum and prompted to answer a series of three structured questions with clearly stated deadlines. The questions were as follows: 1. Describe a situation in which you personally have experienced a death or loss and how you and your loved ones dealt with it. Tell us what the health care workers did right or wrong; how it made you feel; and if you have any thoughts of how the situation could have been handled differently. 2. What are you seeing in your rotations thus far? Please describe end-of-life situations, discussions with patients/families, giving bad 44

news, interventions, etc. 3. What suggestions do you have for the faculty to enhance palliative care/end-of-life instruction for you, the PA students at the MCG PA Program? In other words, what would you do differently? Students were also directed to complete a posted review on End-of-Life Care8 and take a posttest by the end of the 8-week rotation. Finally, students who remained in Augusta for this rotation were required to attend weekly team meetings at Heartland Hospice in Augusta, Georgia. STUDENT EXPERIENCES Students chronicling their clinical experiences with death and dying was one of the most useful functions of the Wiki Discussion forum. Students learned from one another how to manage their own fears and feelings

about end-of-life issues, with minimal faculty prompting. We heard directly from the students which experiences were most valuable: inpatient care, especially critical care; home visits to a hospice patient; and family conferences at the bedside. Students also shared what did not work well; for instance, attending one or two hospice team meetings was helpful, but more than that was not, especially when meetings did not involve direct patient care. The students repeatedly requested more frequent and more specific instruction in end-of-life symptom management and particularly how to appropriately manage pain — especially opioid dosing — in the critically ill or dying patient. Table 3 identifies the clinical settings most useful to teach end-oflife issues to PA students.

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Table 3. Clinical Settings Conducive to End-of-Life/Palliative Care Instruction Outpatient

Inpatient

Residential/Other

Adult medicine/internal medicine

ICU/critical care

VA residential care facilities

Family medicine

Oncology

Long-term care/skilled nursing facilities

IM subspecialties

Emergency medicine

Outpatient hospice/home health service Jail/prison

-Cardiology -Pulmonology -Nephrology -Neurology

Palliative care unit Inpatient hospice VA hospitals Pediatric hospital settings

Rural health practices

DISCUSSION Table 4 summarizes student recommendations for enhanced palliative care education. During their adult medicine rotation, students participated in online journaling of their experiences with end-of-life issues. From the Wiki Discussion Forum (http://palliativecareforpas.wetpaint. com/forum), we identified which endof-life experiences were most useful for the students. Evidence suggested that some students received more bedside instruction (such as those with ICU/critical care experience or who attended home visits with a hospice nurse) while others received relatively little. It was clear that while students with strictly outpatient adult medicine rotations had significant exposure to chronic care, they rarely experienced an acutely dying patient. Students indicated that the best

Table 4. Student Suggestions to Improve Palliative Care Education What Worked Well

What Did Not Work

End-of-Life Care packet (AAFP Essentials 336)

More than two required hospice team meetings without patient exposure

ICU exposure — a great place to learn end-of-life care

Difficulty getting hospice RNs and staff to call back to arrange home visits

Wiki Discussion — hearing other students’ experiences

Not enough knowledge in opioid dosing and symptom management

Witnessing end-of-life discussions with patients and families at bedside

Uneven exposure to critical/dying patients in adult med rotation depending on adult med setting (inpatient vs. outpatient, etc.)

Recommendations for Future PA Students Learn about dying process just like other pathologic processes

Dedicated 1-week clinical medicine block to palliative care education

Teach approach to palliative care patient

How to discuss withdrawing care

More case studies

More home health and long-term care exposure

More about treatment options

Incorporate palliative care exposure earlier, ie, in didactic year

5 weeks of adult med outpatient with hospital rounds; 2 wk ICU; 1 wk PC/hospice

More on comfort measures vs. invasive treatments

More dedicated time in hospice

More classroom instruction in end-of-life issues

More time in ICU

Hospice shadowing should be required at least once

More on how to give bad news

Guaranteed exposure to end-of-life patients in rotations

Palliative care role play

Hospice referral protocol


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methods of instruction occurred in small groups and at the bedside. They desired more frequent and specific instruction in pain management and more supervised experiences in hospice and palliative care units. The students suggested a series of smaller lectures, case-based teaching, and more training in comfort care orders. They also expressed a need for more classroom instruction in end-of-life care before starting rotations.

reform may enable PAs to refer to hospice and home health care. PAs will be well-suited to perform these roles if they are properly prepared. The roots of our profession have grown out of answering unmet health care needs. As our nation’s population and health delivery systems face increasing demands for end-of-life care, PAs trained in palliative care will be an asset to their practice and community.

in end-of-life care: a national report. J Gen Intern Med. 2003;18:685695. 7. Bailey FA. Comfort care order set: last hours of life. In: The Palliative Response. Birmingham, AL: Menasha Ridge Press; 2005:293-294. 8. Winn PA, Salinas RC, Cook JB. End-of-Life Care. Leawood, KS: American Academy of Family Physicians; May 2007.

Recommendations/Future Directions

REFERENCES

Palliative Care Resources for Clinicians, GetPalliativeCare.org: http://www.getpalliativecare.org/ resources

The MCG experience may be generalizable to other PA programs that have traditionally emphasized curing disease over palliation. Many PA program curricula are modeled after medical education, which tends to promote treatment and healing, but does not often teach strategies for allowing patients to die with dignity. It is not surprising that practicing PAs and PA students often feel unprepared when faced with a dying patient, if they have not been taught how to counsel and manage palliative care options. With the updated Standards,1 PA educators are required to incorporate end-of-life/palliative care instruction into the didactic and clinical curricula. There are many different ways to teach end-of-life care. Palliative care and hospice are interdisciplinary by design, making interprofessional courses an effective way to teach these concepts. New roles for PAs in palliative care units and hospice are rapidly developing. Further health care

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Accreditation Review Commission on Education for the Physician Assistant. Accreditation Standards for Physician Assistant Education, Fourth edition, March 2010. http://www.arcpa.org/documents/Standards4thediti onFINAL3.22.10.pdf. Accessed April 13, 2010. Berge NE, Prerost FJ, Foltz PF. Attitudes of physician assistant students to hospice care and assisted suicide. Perspect Physician Assist Educ. 2001;12:177-180. American Academy of Physician Assistants. End-of-Life Decision Making. http://www.aapa.org/images/stories/ documents/about_aapa/policymanual/16-EndofLife.pdf. Accessed June, 22, 2009. Ury WA, Reznich CB, Weber CM. A needs assessment for a palliative care curriculum. J Pain Symptom Manage. 2000;20(6):408-416. Opacic D, Petersen M. Pilot project: Palliative care concepts in physician assistant education. Poster presented at: APAP 2005 Education Forum; November 2-6, 2005; Las Croabas, Puerto Rico. Sullivan AM, Lakoma MD, Block SD. The status of medical education

Educator Resources for Teaching Palliative Care

The EPEC Project, Education in Palliative and End-of-Life Care, Feinberg School of Medicine, Northwestern University: http:// www.epec.net/EPEC/Webpages/ resources.cfm EPERC, End of Life/Palliative Education Resource Center, Medical College of Wisconsin: http://www. eperc.mcw.edu/ Institute to Enhance Palliative Care, University of Pittsburgh: http://www. dom.pitt.edu/dgim/IEPC/resources_ information.html; “Case of the Month” includes an extensive collection of palliative/end-of-life case studies that could be adapted to small group learning and ethics discussions Medical College of Georgia PA Program Palliative Care Wiki: http:// palliativecareforpas.wetpaint.com/

2010 Vol 21 No 4 | The Journal of Physician Assistant Education